Effectiveness of psychological intervention following sport injury

Abstract

With increasing attention given to the development and implementation of psychological interventions during the sport injury rehabilitation process, there is a need to document the effectiveness of these interventions. The purpose of this review was to summarize the empirical findings of the effects of psychological interventions in reducing post-injury psychological consequences and improving psychological coping during the injury rehabilitation process among competitive and recreational athletes. In February 2012, utilizing a comprehensive search strategy, we conducted electronic searches of multiple electronic databases for randomized and nonrandomized control trials that evaluated interventions targeting populations of injured competitive and recreational athletes age 17 years and older. We included interventions that directly intervene on injured athletes' psychological outcomes (e.g., psychological consequences, psychological coping and re-injury anxiety) and utilized psychological strategies including imagery, goal-setting, relaxation, and other common techniques during the post-injury rehabilitation period. Six studies, described in seven peer-reviewed published articles, met study inclusion criteria and were included in this review. Of those studies, two included randomized control trials, two used before and after study designs and two were case study designs. Two interventions utilized guided imagery and relaxation, two interventions utilized goal-setting and one each utilized microcounseling, written disclosure, and acceptance and commitment therapy. Guided imagery/relaxation was shown to be associated with improved psychological coping and reduced re-injury anxiety. Goal setting, however, was not directly associated with the reduction of negative psychological consequences. Other psychological techniques such as microcounseling skills, acceptance and commitment therapy, and written disclosure have demonstrated effectiveness in reducing negative psychological consequences, improving psychological coping, and reducing re-injury anxiety. Our findings suggest a significant need to develop and implement well-designed intervention studies that target improvement of post-injury psychological outcomes in order to assist injured athletes successfully recovery from sport injury.

Full text

Review
Effectiveness of psychological intervention following sport injury
Laura M. Schwab Reese
a
, Ryan Pittsinger
b
, Jingzhen Yang
a,
*
a
Department of Community and Behavioral Health, The University of Iowa, Iowa City, IA 52242, USA
b
Department of Psychological and Quantitative Foundations, The University of Iowa, Iowa City, IA 52242, USA
Received 21 April 2012; revised 4 June 2012; accepted 6 June 2012
Abstract
With increasing attention given to the development and implementation of psychological interventions during the sport injury rehabilitation
process, there is a need to document the effectiveness of these interventions. The purpose of this review was to summarize the empirical findings
of the effects of psychological interventions in reducing post-injury psychological consequences and improving psychological coping during the
injury rehabilitation process among competitive and recreational athletes. In February 2012, utilizing a comprehensive search strategy, we
conducted electronic searches of multiple electronic databases for randomized and nonrandomized control trials that evaluated interventions
targeting populations of injured competitive and recreational athletes age 17 years and older. We included interventions that directly intervene on
injured athletes’ psychological outcomes (e.g., psychological consequences, psychological coping and re-injury anxiety) and utilized psycho-
logical strategies including imagery, goal-setting, relaxation, and other common techniques during the post-injury rehabilitation period. Six
studies, described in seven peer-reviewed published articles, met study inclusion criteria and were included in this review. Of those studies, two
included randomized control trials, two used before and after study designs and two were case study designs. Two interventions utilized guided
imagery and relaxation, two interventions utilized goal-setting and one each utilized microcounseling, written disclosure, and acceptance and
commitment therapy. Guided imagery/relaxation was shown to be associated with improved psychological coping and reduced re-injury anxiety.
Goal setting, however, was not directly associated with the reduction of negative psychological consequences. Other psychological techniques
such as microcounseling skills, acceptance and commitment therapy, and written disclosure have demonstrated effectiveness in reducing
negative psychological consequences, improving psychological coping, and reducing re-injury anxiety. Our findings suggest a significant need to
develop and implement well-designed intervention studies that target improvement of post-injury psychological outcomes in order to assist
injured athletes successfully recovery from sport injury.
Copyright Ó2012, Shanghai University of Sport. Production and hosting by Elsevier B.V. All rights reserved.
Keywords: Intervention; Psychological consequence; Psychological coping; Sport injury
1. Introduction
Sport injuries frequently have profound negative conse-
quences on the physical health of sports participants.
1,2
They
also have the potential to cause a great deal of psychological
disturbance through increased anger, depression, anxiety,
tension, fear, and decreased self-esteem.
3e23
Sport injuries
often result in an immediate imbalance and disruption to the
lives of the injured athletes including loss of health and
achievement of athletic potential.
24,25
In extreme cases,
injuries result in a permanent disability or even death.
26e31
Such functional loss or the inability to continue sports
participation can be devastating and hinder the recovery
process, and consequently affect the way athletes mentally
deal with future injuries.
15,23
Thus, including a component that
addresses psychological recovery from a sport injury in the
traditional injury rehabilitation program becomes critical to
* Corresponding author.
E-mail address: jingzhen-yang@uiowa.edu (J. Yang)
Peer review under responsibility of Shanghai University of Sport
Production and hosting by Elsevier
Available online at www.sciencedirect.com
Journal of Sport and Health Science 1 (2012) 71e79
www.jshs.org.cn
2095-2546/$ - see front matter Copyright Ó2012, Shanghai University of Sport. Production and hosting by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jshs.2012.06.003

preventing and/or reducing negative psychological conse-
quences resulting from the injury and promoting return to
active involvement in sport-related activities.
Increasing attention has been given to the development and
implementation of psychological interventions during the
sport injury rehabilitation process in recent years.
32
Many
sport injury rehabilitation programs are beginning to integrate
psychological interventions into the treatment regimens in
order to expedite both physical and psychological recovery
from injury.
33e41
The psychological techniques commonly
used with injured athletes in these interventions include
relaxation,
35,38
mindfulness, imagery,
34,35,38
goal setting,
36e38
and stress management.
34,38e41
Existing studies indicated
these psychological interventions help reduce negative
psychological consequences,
36e40
improved coping
skills,
36,37,39e41
and reducing re-injury anxiety.
35,41
As a result
of improved psychological well-being, injury recovery period
is shortened and injured athletes frequently return to play
sooner.
42
Despite growing interest in utilizing psychological
interventions, few controlled outcome studies have been
published. Empirical evidence demonstrating that psycholog-
ical interventions decrease negative psychological conse-
quences or increase psychological coping still remains
limited.
Advances in medical treatments have reduced the time
required for physical healing, which may result in athletes who
are physically healed and ready to return to play but not yet
psychologically recovered.
43,44
This potential discrepancy
between psychological and physical recovery calls for increased
attention to the recovery process for injured athletes. Under-
standing the role of psychological and other factors contributing
to injury recovery will provide a critical foundation for the
development, implementation, and evaluation of psychological
interventions, which will subsequently improve the recovery
process for injured athletes. The objective of this review was to
summarize the empirical findings on the effects of psychological
interventions in reducing post-injury psychological conse-
quences, and/or improving psychological coping during the
injury rehabilitation process among competitive and recrea-
tional athletes.
2. Materials and methods
2.1. Types of studies
We included randomized control trials (RCTs), nonRCTs
that utilize a comparison group, before and after study designs,
and qualitative methods.
2.2. Types of participants
We included intervention studies with target populations of
severely injured competitive and recreational athletes age 17
years and older. Severe injury is defined as an injury which
results in at least 3 weeks away from play.
45
We excluded
interventions among children and adolescents due to signifi-
cant differences in psychological intervention strategies
employed to youth and adult population related to develop-
mental differences.
2.3. Types of interventions
We included studies that evaluated the effectiveness of
psychological interventions with the aims of reducing post-
injury psychological consequences (including symptoms
related to depression, anxiety, and generalized psychological
distress) and/or improving psychological coping (including
reducing re-injury anxiety) among injured athletes. We defined
psychological interventions as those that utilized psycholog-
ical strategies including imagery, goal-setting, relaxation, and
other common techniques that were implemented during the
post-injury rehabilitation period.
We excluded studies that did not include interventions that
directly intervened with injured athletes’ psychological
consequences or the psychological coping process. This
exclusion included programs that taught athletic trainers and/
or other professionals to use psychological techniques with
injured athletes but did not evaluate the effect of the inter-
vention specific to outcomes in injured athletes.
2.4. Types of outcome measures
We included studies that reported any of the following
outcome measures:
1. Reduction in psychological consequences including
decreased anxiety and feelings of devastation, restlessness,
and dispiritedness;
2. Increase in psychological coping including improved
mood, self-efficacy, and psychological flexibility;
3. Reduction in re-injury anxiety.
2.5. Search methods of identification of studies
We conducted comprehensive electronic searches and
searched the following electronic databases:
Academic Search Elite
ERIC
Health Source: Nursing/Academic Edition
PubMed
PsychINFO
We searched these databases, with a restriction to English
language. The initial searches were based on the following
keywords:
1. Psychological recovery AND athletic injury or sports
injury;
2. Psychological factors AND athletic injury or sports injury;
3. Psycholog* AND sports injury rehabilitation or athletic
injury rehabilitation.
A total of 991 relevant articles were identified through
these search terms. We excluded articles that were published
72 L.M. Schwab Reese et al.

prior to the year 2000 (n¼311) and conducted second round
searches among the remaining 680 articles using the following
10 search terms: “intervention”, “interv*”, “cognitive
therapy”, “behavior* therapy”, “relaxation”, “goal-setting”,
“guided imagery”, “acceptance”, “commitment”, “ACT”
(acceptance and commitment therapy). A total of 157 relevant
articles remained after the second round search. We reviewed
the titles and abstracts of the 157 articles and further excluded
128 studies that did not report the study population of interest
or the outcome of interest. All three authors reviewed the
remaining 29 articles for relevance and the agreement was
reached to exclude 22 articles that did not meet the study
inclusion criteria based on the type of participants, interven-
tion, or outcome measures. Thus, the remaining seven articles
that met the study inclusion criteria regarding the type of
participants, intervention, and outcome measures were
included (Fig. 1). For the purposes of this review, two publi-
cations, which reported the findings of a single study, are
treated as one study.
3. Results
3.1. Types of studies
The seven included articles published on six studies were
evenly divided between three research designs (Table 1). Two
studies (33%) included RCTs.
35,36
Evans and Hardy
37
included an in-depth qualitative follow-up after completion
of the initial RCT. Two studies used before and after study
designs.
38,39
Two studies were case study designs.
40,41
Two
studies (33%) were conducted in Australia and one study
(17%) in each the USA, England, Wales, and Sweden.
3.2. Types of participants
All six studies included competitive athletes as study
participants and two studies also included recreational level
athletes.
35e37
All studies included adult participants with one
study also including 17-year-old minors.
36
Participants in the
studies ranged from age 17 to 50. Four studies (66%) recruited
men and women approximately evenly, while two additional
studies (33%) recruited many more male participants than
female participants. Three studies (50%) recruited only
athletes with anterior cruciate ligament (ACL) injuries.
35,40,41
Three studies (50%) recruited athletes with any long-term
injury.
36e39
Knee injuries, including ACL injuries, were the
most common injury. Other injuries included in these studies
were neck, shoulder, leg, and/or foot injuries. All six studies
recruited participants who played a variety of sports with
football (soccer) as the most common sport played, followed
by basketball, rugby, skiing, and tennis.
3.3. Types of interventions
Three studies (50%) included multiple intervention
techniques.
35e38
In Johnson,
38
participants in the intervention
group received three brief psychological intervention sessions
focusing on stress management, goal-setting, and relaxation/
guided imagery, respectively. Each session lasted 15e25 min.
The control group received regular rehabilitation programs
with no form of psychological intervention.
Evans and Hardy
36,37
had three intervention levels. Partici-
pants were randomly assigned to one of three groups: goal-
setting intervention, social support control, and control group.
Participants were matched according to physiotherapist, injury
type, rehabilitation stage, sport, level of participation, and
gender.
36
Participants assigned to the goal-setting intervention
met with a sports psychologist for 60e105 min four to five
times over a 5-week period, in order to set process and outcome
goals based upon the participants’ specific situations. During
each session, progress toward goals was reviewed and served as
the basis for the next set of goals. Participants in the social
support control group met with a sports psychologist four to five
times over a 5-week period for 40e60 min. During each
Fig. 1. Flowchart of article selection process.
#
Search terms included: interv* or cognitive therapy or behavior* therapy or relaxation or goal-setting or imagery or
guided imagery or acceptance or commitment or ACT* (acceptance and commitment therapy).
Psychological intervention following sport injury 73

Table 1
Characteristics and core component of included intervention studies.
Studies Methods Participants Interventions Outcomes
Johnson
(2000)
38
Modified 2-group,
pretreatment and
post-treatment
(repeated measure)
Fifty-eight
competitive-level
athletes (52 men
and 6 women) with
an age of 23.74.3
years (mean SD)
who suffered traumatic
and severe injuries
while training and/or
during competition
that prevented them
from engaging in sport
for a minimum
of 5 weeks.
Treatment group: Fourteen
participants received a formal
intervention performed by a
sport psychologist in stress
management and cognitive
control, goal-setting skills, and
relaxation/guided imagery
during their traditional sports
medicine physiotherapy treatment
on three different occasions lasting
in duration from 15 to 25 min.
Control group: Forty-four participants
engaged in regular sports medicine
physiotherapy treatment directed by
a physiotherapist and did not receive
any form of psychological intervention.
Mood adjective checklist: six
bipolar mood dimensions.
Patient’s self-rating questionnaire:
self-reported readiness to return to sport.
Psychosocial risk factors and sport
injury: psychological risk factors
including goal setting, stress, mood,
coping strategies.
Cupal & Brewer
(2001)
35
Randomized
controlled
clinical trial
Thirty competitive
and recreational
athletes (16 men
and 14 women)
ranging in age
from 18 to 50
years (28.2 8.2,
mean SD) who
underwent arthroscopic
reconstructive ACL
surgery, had no
evidence of any
other acute lower
extremity trauma,
and expected to
engage in postsurgical
rehabilitation for at
least 6 months.
Treatment group: Ten participants
engaged in 10 individual sessions of
relaxation and guided imagery in
addition to the normal course of
physical therapy, beginning
2 weeks post-surgery.
Sessions were spaced 2 weeks
apart over a 6-month period.
Placebo group: Ten participants
engaged in sessions receiving
attention, encouragement, and
support from a sports medicine
clinician in addition to the
normal course of physical therapy.
Control group: Ten participants
engaged in just the normal
course of physical therapy.
Self-reported knee strength, level
of re-injury anxiety, and level of pain.
Rock & Jones
(2002)
40
Case studies Three participants
(2 males and 1 female)
ages 31, 35, and 40
who identified as an
athlete and underwent
ACL surgery due to
athletic injury.
Treatment group: Participants received
counseling-skills interventions at 3 days,
2, 4, 6, 8, and 10 weeks post-surgery.
Counseling-skills intervention sessions
lasted between 40- to 60-min and were
centered upon the integrative-skills model
of counseling which is a skills-based and
flexible model. Skills such as reflection,
paraphrasing, and summarizing were
implemented in order to develop rapport
and establish empathy, acceptance, and
genuineness.
Mood, perceived rehabilitation,
pain ratings, and social support.
Evans & Hardy
(2002)
36,37
Single blind
randomized
control trial;
Qualitative
follow-up
Thirty-nine injured
athletes (33 males,
6 females; age 17e39
years) who had
missed at least
5 weeks of training
and/or competition.
Experimental goal-setting
intervention group: Participants
met with a sport psychologist for
60e105 min every 7e10 days for
5 weeks. Sessions developed and
provided feedback on goals with
daily diary completion related to
goal progress.
Social support control group:
Participants met with a sports
psychologist for 40e60 min every
7e10 days for 5 weeks. During the
session, the psychologist acted as a
social support including emotional
and listening support with daily
Rehabilitation adherence: measured
by self-reported& physiotherapist
estimated rehabilitation activities.
Sports injury rehabilitation beliefs
survey: self-reported self-efficacy and
treatment efficacy.
Psychological response to sport
injury inventions: devastation,
dispirited, feeling cheated, restlessness,
and reorganization.
(continued on next page)
74 L.M. Schwab Reese et al.

session, the sports psychologist provided social support
consistent with the type of social support provided in the goal-
setting group. Participants in the control group received a tele-
phone call every 10 days, ranging in duration from 5 to 10 min.
Of the 30 participants in Cupal and Brewer’s study,
35
10
were assigned to a treatment, placebo, and control group
respectively. Participants in the treatment group received 10
individual relaxation and guided imagery sessions, occurring
every 2 weeks, in addition to their regular physical therapy
treatment. The intervention focused on reframing participants’
perception by encouraging positive coping, and using imagery
modalities to encourage vivid mental imagery. Participants in
the placebo group received support and attention from
a clinician and were advised to spend time everyday visual-
izing a peaceful scene in addition to regular physical therapy,
while control group participants received only regular physical
therapy with no additional intervention.
Rock and Jones,
40
Mankad and Gordon,
39
and Mahoney
and Hanrahan
41
each implemented a single type of interven-
tion technique among injured athletes. Rock and Jones
40
conducted a series of case studies in the United Kingdom
among three competitive athletes who had ACL damage but
no history of surgical treatment. The participants received
a microcounseling skills intervention initially 3 days after
surgery, and then every other week thereafter. The intervention
provided active listening, reflection, paraphrasing, and
summarization in order to build rapport and develop an
empathic, accepting, and genuine environment.
Mankad and Gordon
39
conducted a written disclosure
intervention among injured athletes on 3 consecutive days
3 months after surgery. Participants were instructed to think
about the injury experience and to write for 20 min about their
negative injury-related thoughts, emotions, and feelings. The
intervention provided injured athletes the opportunity to reflect
on the injury experience and related emotions which increased
the perceived sense of control.
Mahoney and Hanrahan
41
completed a case series in
Australia with four competitive athletes who experienced ACL
injuries. Following reconstructive knee surgery, participants
attended weekly individual education sessions for 4 weeks.
During each session, a different component of ACT was
introduced including, cognitive defusion, mindfulness-based
strategies, acceptance, and values clarification. Two additional
components of ACT, using the self as context and committed
action, were implicit during all four sessions.
3.4. Types of outcomes
Four (66%) studies measured participants’ negative
psychological consequences related to injury including mood
Table 1 (continued)
Studies Methods Participants Interventions Outcomes
diary completion related to
rehabilitation progress.
Control group: Participants were
reached by phone every 10 days
for 5e10 min. Participants completed
a training log with the frequency and
nature of rehabilitation activities.
Mankad & Gordon
(2010)
39
Repeated-measures
design
Nine injured elite
athletes (4 males,
5 females; age
18e29 years)
during post-injury
rehabilitation.
Treatment group: Participants
completed a 3-consecutive-day
written emotional-disclosure
intervention. They were directed
to write for 20 min each day about
their injury experience including
their deepest emotions and thoughts,
preferably thoughts that had not been
previously shared.
Psychological response to sport
injury inventions: measures
devastation, dispirited, feeling
cheated, restlessness, and
reorganization.
Rehabilitation beliefs survey:
measures self-efficacy, treatment
efficacy, susceptibility to reinjury,
severity, and rehabilitation value.
Linguistic inquiry work count:
assesses affect, positive emotion,
negative emotion, cognition, insight,
and causation.
Mahoney & Hanrahan
(2011)
41
Case study Four injured athletes
(2 males, 2 females;
age 18e49 years)
during ACL
rehabilitation.
Treatment group: Participants
attended weekly one-on-one
sessions with a trained therapist
for four weeks following
reconstructive knee surgery.
Each session a different component
of ACT was introduced including:
cognitive defusion, mindfulness,
acceptance, and values. The
sessions were standardized so
each participant was exposed
to the same material.
Acceptance & action questionnaire-II:
measures psychological flexibility.
Mindfulness attention awareness
scale: measures tendencies to be
attentive and aware of present moment.
Sport injury anxiety scale: measures
anxieties related to athletic injury.
Abbreviations: ACL ¼anterior cruciate ligament; ACT ¼acceptance and commitment therapy.
Psychological intervention following sport injury 75

disturbance, devastation, restlessness, and feelings of being
cheated.
36e40
Five (83%) studies measured participants’ abil-
ities to psychologically cope with injury and rehabilitation,
including psychological flexibility, mood, self-efficacy,
mindfulness, and perceived social support.
36e41
Two (33%)
studies measured participants’ re-injury anxiety.
35,41
Re-injury
anxiety is defined broadly as concern about injury upon return
to regular physical activity.
3.5. Effects of interventions
3.5.1. Negative psychological consequences
Four reviewed studies focused on reduction of negative
psychological consequences.
36e40
In a RCT conducted by
Evans and Hardy,
36
77 enrolled seriously injured recreational
and competitive athletes in Wales were randomly assigned to
one of three groups: goal-setting intervention, social support
control, and control group. Results showed that while all three
groups experienced decreased dispirited feelings defined as the
loss of motivation and apathy at the end of the study, no
significant differences were found between the three groups
for dispirited feelings.
Following completion of the RCT, three participants from
each of the intervention groups and the control group (total of
nine participants), were further purposefully selected to
complete a semi-structured interview lasting 50e105 min.
37
Results revealed all participants in all three groups experi-
enced periods of positive emotions alternating with periods of
depression and frustration.
The Evans and Hardy results
36,37
are consistent with find-
ings from Johnson’s study
38
which showed no significant
differences in feelings of stress and worry after injury between
intervention and control group. However, in contrast to Evans
and Hardy
36,37
and Johnson,
38
the findings from Rock and
Jones
40
and Mankad and Gordon
39
included in this review
support the role of psychological interventions in decreasing
negative consequences associated with sport injury. The
results from Rock and Jones
40
and Mankad and Gordon
39
revealed participants experienced decreased mood distur-
bance and fewer negative feelings and emotions related to
injury following intervention. Following Rock and Jones’s
40
microcounseling skills intervention, setbacks in rehabilitation
progress still resulted in increases in mood disturbance but the
intervention reduced the severity of the mood disturbance.
Mankad and Gordon
39
also found that after engaging in
written disclosure, athletes reported decreased feelings of
being cheated, devastated, restlessness, tension, emptiness,
and difficulty accepting the injury as well as fewer exhibited
avoidance behaviors.
3.5.2. Psychological coping
Five studies reported on increases to positive psychological
coping including psychological flexibility, mood, self-efficacy,
mindfulness, and perceived social support.
36e41
Johnson
38
conducted a RCT among 58 Swedish national competitive
level athletes who sustained traumatic and severe sport injuries
that required, on average, 12.4 weeks of rehabilitation prior to
returning to play. Results showed that athletes in the inter-
vention group (n¼14) reported significantly better mood
scores compared with athletes in the control group (n¼44),
including increased feelings of pleasure, social orientation,
and security. Athletes in the intervention group also reported
feeling more prepared for competition at the end of rehabili-
tation when compared to athletes in the control group.
Increased psychological coping skills following psycho-
logical intervention is consistent with the results from four
other studies reviewed.
36,37,39e41
Social support and support
seeking behaviors increased in participants who completed
psychological intervention. Evans and Hardy
37
found partici-
pants who received a goal-setting intervention or a social
support intervention had higher levels of perceived social
support. Following a written disclosure intervention, confi-
dence and general enjoyment increased
39
and participants re-
ported an increased ability to accept their situation and injury-
related emotions after completing an educational ACT inter-
vention.
41
However, Johnson
38
found no differences between
the participants in the intervention and control groups with
regard to positive feelings toward rehabilitation or feelings of
stress/worry.
3.5.3. Re-injury anxiety
Cupal and Brewer
35
conducted a RCT among 30 recreation
and competitive athletes in the USA who had undergone ACL
reconstructive surgery, but experienced no other lower
extremity trauma, and were expected to take part in rehabili-
tation for at least 6 months. Results showed a significant
decrease in re-injury anxiety among participants who received
a relaxation and guided imagery intervention compared to
participants in the placebo and control groups. Participants in
the intervention group also reported lower perceived pain
compared to the placebo and control groups.
35
However, this
finding was not consistent with the results of Mahoney and
Hanrahan’s
41
investigation, which found re-injury anxiety was
not altered in participants after engaging in a brief ACT
educational intervention.
4. Discussion
Psychological factors are being increasingly recognized by
sports medicine professionals as important during the reha-
bilitation process from sport injury.
46e50
Using a comprehen-
sive search strategy, this review of psychological techniques
employed with injured athletes illustrates a significant lack of
well-designed intervention studies targeting this population.
Only six intervention studies specifically addressed the
effectiveness of the psychological interventions in the context
of psychological rehabilitation from sport injury. Our findings
showed that psychological interventions utilizing guided
imagery, goal setting, or relaxation are often associated with
decreased negative psychological consequences, improved
coping, and reduced re-injury anxiety. This review adds to the
literature on psychological recovery from sports injury and has
implications for future research and practice.
76 L.M. Schwab Reese et al.

Guided imagery was used in two out of the six studies
included in this review and was applied with injured athletes
along with relaxation and other psychological techniques in
order to facilitate increased concentration and vividness specific
to a given task.
35,38
Imagery was traditionally defined as “the
process of imaging the performance of a skill with no related
overt actions”.
51
More recently, imagery has been also defined
as the creation or re-creation of an experience that is under the
control of the imager and may occur without the stimulus
antecedents associated with the experience.
52
The practice of
imagining or visualizing an experience without physically
completing the task increases the ability to mentally prepare by
imagining successful completion.
53
During an imagery inter-
vention, injured athletes are asked to image a scenario directly
or indirectly related to injury recovery. They may be prompted
to imagine the process they will embark on during their injury
rehabilitation including the different phases of rehabilitation,
their progress during each of the phases, the emotions they may
experience, as well as the successful completion and return to
full sport engagement after completing the rehabilitation
process. In Johnson’s study,
38
injured athletes were taught how
to mentally connect their mind with the injured body part and
imagine healing taking place, as well as imagining their body
functioning perfectly and performing their desired activities
well. The results showed that injured athletes’ overall mood was
improved after the intervention.
38
Relaxation is another cognitive strategy that has been used
to reduce stress, anxiety, and mental/physical strain in the
studies reviewed. By increasing the athletes’ awareness of
their physiological and psychological arousal level, relaxation
techniques can help injured athletes regulate their levels of
arousal for achieving optimal outcomes. Evidence showed that
relaxation can reduce the feelings of depression, frustration,
and anger through lowering heart rate, breathing rate, meta-
bolic rate, and blood pressure.
54
One useful relaxation technique often taught to athletes is
engaging in deep breathing. In the Johnson
38
and Cupal and
Brewer
35
studies, injured athletes were taught to take deep
diaphragmatic breaths instead of breathing simply from the
lungs in order to assist in calming down and/or refocusing their
attention to the immediate experience of the here-and-now.
Deep breathing could also assist in the physiological shift of
lowering heart rate, blood pressure, as well as salient psycho-
logical factors.
55
Through this refocusing, injured athletes are
better prepared to face the challenges of a specific task instead
of merely thinking about the challenges that may cause
unwanted pressure and anxieties due to the injury. In Cupal and
Brewer’s study,
35
athletes were taught to breathe deeply as
a method of relaxation to help reduce anxiety and decreasing
affective distress among athletes with ACL injuries.
Incorporating goal setting as a technique to reduce
psychological distress during the rehabilitation process was
implemented in studies conducted by Johnson
38
and Evans and
Hardy.
36,37
Goal setting is believed to enhance an individual’s
ability to accomplish a given task by providing individuals
with a sense of direction to focus their efforts, by increasing
the degree of persistence, and by furthering the development
and refinement of new strategies aimed to successfully
completing a task.
56
In the Johnson
38
and Evans and
Hardy
36,37
studies, goal setting also led to an increase in self-
efficacy and/or self-confidence as a result of accomplishing
a set goal during the rehabilitation process.
56
Other techniques such as education ACT sessions, basic
microcounseling skills and written expression have been found
to be effective in mitigating the post-injury psychological
distress among injured athletes.
41
ACT is a third-wave cognitive
behavioral therapy (CBT) approach, which has received
considerable attention and support in current literature for its
usefulness and effectiveness in both clinical and sport specific
settings.
41,57,58
ACT emphasizes the importance of increasing
mindfulness and psychological flexibility.
57
As a result, injured
athletes improve their “ability to connect with the present
moment fully as a conscious human being and to change or
persist in behavior when doing so serves valued ends”.
41
The
implementation of basic microcounseling skills (attending,
active listening, empathy, and reflection) by a mental health
professional has also been shown to have the effect of enhancing
the psychological well-being of injured athletes during the
rehabilitation process.
40
Through the use of basic micro-
counseling skills, injured athletes are provided emotional and
listening support, which are empirically-supported key func-
tions of the counseling process.
40
Similarly to engaging in
verbal expression, one of the hallmark elements of “talk
therapy”, written expression has also been shown to be an
effective form of emotional disclosure that contributes to
improving the psychological rehabilitation of injured athletes.
Expressive writing allows injured athletes to construct written
narratives depicting their emotional experiences as well as
engage in a self-regulatory process facilitating an increased
sense of control over their emotions.
59
4.1. Strengths and limitations of studies included
While the studies included in this review demonstrate
growing empirical evidence of integrating psychological
techniques into the rehabilitation process following sport
injury, these studies are limited by small sample size, which
makes it difficult to detect intervention effects due to a lack of
statistical power. Furthermore, these studies often have a short
follow-up time, thus the long-term effects of these interven-
tions often are unknown. Despite these limitations, the
reviewed studies demonstrated positive intervention effects
specific to several aspects of psychological recovery including
reducing negative psychological consequences, increasing
positive coping, and decreasing re-injury anxiety. Our findings
provide empirical data for future studies that examine the
effects of psychological interventions. Our findings demon-
strate the urgent need for additional research examining the
effects of psychological interventions utilizing rigorous
methodology which includes utilizing RCT or prospective
study design, inclusion of a control group, consistent and
improved outcome measures, accounting for potential
confounders in the analysis, and increased diversity of study
populations to increase generalizability.
Psychological intervention following sport injury 77

4.2. Limitations of this review
Despite the wide research design inclusion criteria, only six
interventions were included in this review. While the varia-
tions in research designs and intervention outcomes provide
insight into the wide range of techniques available to sports
psychologists and other professionals involved in the reha-
bilitation process,
35e41
the limited number of studies
employing each type of technique prevented further compre-
hensive analysis. Thus, our ability to draw a conclusion on
effectiveness of psychological interventions was limited.
Furthermore, this review only included intervention strategies
with individual injured athletes. Many intervention strategies
that target changes at interpersonal, organizational, and policy
level(s) to improve outcomes of psychological rehabilitation,
such as increased social support from the team or athletic
trainers, or psychological counseling services at athletic
department, were not included.
60e64
5. Conclusion
In conclusion, the results of this review support the effec-
tiveness of psychological intervention in reducing post-injury
psychological consequences and improving psychological
coping during rehabilitation. Specifically, guided imagery/
relaxation was shown to be associated with improved
psychological coping and reduced re-injury anxiety. Goal
setting however, was not directly associated with reduction of
negative psychological consequences. Other psychological
techniques such as microcounseling skills, ACT, and written
disclosure included in this review have demonstrated reduced
negative psychological consequences, improved psychological
coping, and reduced re-injury anxiety.
Many techniques discussed in this review are routinely
employed by applied sport psychologists and there is an abun-
dant amount of empirical data supporting the use of above-
mentioned psychological strategies to aid in or enhance athletic
performance.
47e50,61e73
Research examining the effectiveness
of employing the psychological intervention with injured
athletes during sport injury rehabilitation is significantly lack-
ing. Our findings highlight the importance of development,
implementation and evaluation of the effectiveness of inter-
vention strategies through research so these evidences can be
utilized to assist injured athletes’ successful recovery.
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