Sports Based Injury Rehabilitation - Essay Example

?Drawing on the relevant research literature, critically discuss the relative merits of various psycho-social intervention strategies to help athletes expedite their re-entry into competitive sport. Sports based injury rehabilitation has evolved over the decades. Previously the focus lay with physical rehabilitation to achieve pre-injury performance levels. However, of late there has been a growing trend to include psychosocial factors as well as psychological factors in athlete injury rehabilitation. The conglomeration of a number of factors in athlete rehabilitation after injury means that the resulting models are complex. Common factors are generally identified for rehabilitation in nearly all of the models in use but there is disagreement as to the relative weightage of factors in use. Moreover, certain literature has concentrated on evaluating previously formulated models in order to expand on or to improve such models. This text will attempt to review the literature present on athlete rehabilitation after injury in order to develop a clearer picture on the models in use. A number of differentiated and related models as well as theories have been used in order to delineate sport injury rehabilitation. Perhaps the best known of these models has been the integrated model of sport injury rehabilitation (Wiese-Bjornstal et al., 1998). In recent years the biophyschosocial model of sport injury rehabilitation (Brewer et al., 2002) has gained widespread attention in the sports injury rehabilitation domain. Some old models such as those proposed by Kubler-Ross (1969) consisting of stage based grief response have also been expanded on in recent years. The stage model of the return to sport proposed by Taylor and Taylor (1997) is also worth looking into given the derivation of its parts from other models. In addition to the models in use, a number of theories have also been expounded in order to delineate sports injury rehabilitation. The self-determination theory (SDT) (Ryan & Deci, 2000) has gained prominence in recent years and can be seen as related to the self-efficacy theory in structure (Bandura, 1997). These theories are differentiated from the cognitive motivational relational theory of emotions proposed by Lazarus (2000). In previous decades a number of other theories were also proposed to delineate sports injury rehabilitation including the reversal theory (Apter, 1982), protection motivation theory (Rogers, 1975) and the personal investment theory (Maehr & Braskamp, 1986). In order to understand these models and theories it would be pertinent to look into each proposed mechanism separately. However, the best possible approach would be to start out with more holistic models that tend to account for a number of factors. This would allow more mature critique of the models and theories that lack a number of psychosocial variables. The first model under discourse will be the integrated model (Wiese-Bjornstal et al., 1998) that has gained prominence due to its holistic approach. The model suggests that both pre-injury and post-injury factors need to be taken into account in order to improve sports injury rehabilitation efforts. Furthermore, this model clearly delineates that the rehabilitation efforts are carried out through a three pronged effort which relies on cognition, emotion and behavioural response. These efforts for improvement are kept in check throughout the process using appraisal methods. The model further suggests that pre-injury and post-injury factors are differentiated from each other. Pre-injury factors for sports injury rehabilitation under the integrated model include: personality (hardiness, optimism etc.); previous history of stressors (daily hassles, major events in life etc.); coping resources (coping strategies, psychological skills etc.). In contrast, the model delineates the post-injury factors as: personal (injury severity, gender, age etc.); situational variables (allowance for social support, significant others, environmental support for rehabilitation, emotional situation etc.); The model also makes it clear that the recovery process is dynamic as well as being interactive and requires the interfacing of cognition, emotion and behavioural response. The interaction between these elements is cyclical in nature and forms an identifiable framework. It must also be highlighted that the recovery from these problems needs to be dealt with on two separate levels – physical and psychological recovery. Here it must be mentioned that the integrated recovery model does make provision for social needs (in the form of environmental variables) but fails to provide them the level of appreciation that personal factors have. It is noticeable that the pre-injury factors are solely based on personal factors alone while the post-injury factors have only one social factor to account for. Based on this observation it may be said that the integrated model can be expanded on and improved further. Over the years, the integrated model to sports injury rehabilitation has been studied and parts of it have been verified and decried at the same time. For example, other research on the issue has found that the factors classified as pre-injury and post-injury factors in the integrated model have noticeable effects on athlete’s recovery in the post injury scenario (Albinson & Petrie, 2003) (Mankad et al., 2009). This position is not just supported by recent research on the issue but these factors were appraised in previous research on the issue as well (Brewer, 1993) (Smith et al., 1990). In a similar manner other research on sports injury rehabilitation has reported the effect of these factors on the cognitive, emotional and behavioural responses of injured athletes. The effects of the pre-injury and post-injury factors from the integrated model have been found to be interactive such that they act in an additive fashion over time as they are applied (Carson & Polman, 2008) (Gallagher & Gardner, 2007) (Podlog & Eklund, 2006). The integrated model for sports injury rehabilitation tends to account for a number of factors but contains some inherent shortcomings as well. The chief limitation presented by the integrated model is the lack of appreciation of rehabilitation outcomes with a set of provided injured athlete responses. In this sense, it could also be stated that the integrated model is not as closely aligned to traditional models of injury as other models on the issue are. This limitation has been covered by later models to delineate sports injury rehabilitation but perhaps the most acclaimed of these attempts is the one by Brewer et al. (2002). The model presented by Brewer and his associates has been labelled as the biopshychosocial model and provides a number of psychological factors that contribute to sports injury rehabilitation and recovery. The psychological factors included in this model comprise of personality, cognition, emotions and behaviour (Brewer et al., 2002). These factors can be seen as closely resembling the interfacing framework of the integrated model (Wiese-Bjornstal et al., 1998) along with an additional factor. In contrast, the rehabilitation outcomes used in the biopsychosocial model consist of functional performance and readiness to return to sporting activities. The biopsychosocial model uses different methods in comparison to the integrated model in order to explain the relationship between inputs and outputs. The model delineates the belief that psychological factors tend to affect rehabilitation outcomes through direct and indirect relationships. Moreover, the psychological factors being considered tend to manifest themselves through bio-psychological outcomes. An improvement in the athlete’s psychological status will manifest itself through a physical improvement such as speedier recovery and vice versa. In addition to the psychological factors, the biological factors such as the metabolism rate, the immunity levels and the endocrine are suggested to be linked reciprocally with psychological factors. Moreover, these biological factors are considered to mediate the relationship that exists between psychological factors and the associated biopsychosocial outcomes. This tends to make a lot of sense as the model tends to cater to a host of different factors through the use of direct, indirect and reciprocal relationships. Most research that has been conducted for psychological factors in relation to sports injury rehabilitation has concentrated on direct relationships alone. These approaches have used biopsychosocial outcomes as intermediate achievements to the overall process’ recovery. In this sense, the rehabilitation outcomes and the intermediate biopsychosocial outcomes can be seen as being investigated from the perspective of direct relationships alone. Validation for the biopsychosocial model has been limited in this respect because direct relationships between variables have been investigated in the past but indirect and reciprocal relationships have received little attention. There is little arguing the fact that the relationship between psychological factors and rehabilitation outcomes is more than direct alone and includes indirect and reciprocal relationships too. There are confirmed relationships between certain psychological factors and their rehabilitation outcomes but these factors need to be expanded upon in order to fulfil the biopsychosocial model. A number of studies have confirmed the relationship between efficient psychological skills (such as imagery, dealing with stress etc.) and the desired rehabilitation outcomes (such as lowered feeling of pain, lowered anxiety, enhanced performance etc.) (Cupal & Brewer, 2001) (Johnson, 2000). In a similar manner other research has shown that cognition, emotion and behavioural responses are related to rehabilitation outcomes that include functional abilities, readiness to return to sport, faster recovery, lowered feeling of pain (Brewer et al., 2004) (Brewer et al., 2000) (Tripp et al., 2007). The confirmation of relationships between psychological factors and rehabilitation outcomes in the biopsychosocial model tends to lend credence to the model. However, the dearth of research on these relationships means that not all factors are confirmed to have a relationship in the biopsychosocial model (Wadey & Evans, 2010). It is expected that as research proceeds, these relationships and their nature (direct, indirect and reciprocal) will become clearer thus adding greater credibility to the biopsychosocial model. This also means that the biopsychosocial model will have to be revised and possibly enlarged as more relationships and their nature becomes firmly established. The larger and more holistic models being used to connect psychological, social and physical characteristics to sports injury rehabilitation have been related above. These models show that some loose aspects still exist where these models are unable to delineate inputs and outputs properly. It must be noticed here that these model tend to account for personal as well as external factors though in different capacities. The integrated model tends to provide limited support for social factors while the biopsychosocial model provides greater coverage. However, this coverage of social factors cannot be accounted for fully because of the limited research on this issue. In addition to these models, there are other more limited models. As explained before, these models will be related in the text provided below for more effective critique on models in literature over sports injury rehabilitation. One of the more quantified models to delineate sports injury rehabilitation has been provided by Milne et. al. (2005). The model has been based on the use of Athletic Injury Self Efficacy Questionnaire (AISEQ) in order to gauge the response of athletes that checks for their responses before, during and after the injury recovery process. The research was aimed to establish the relationships between self-efficacy and the use of imagery with adherence to rehabilitation. It must be noticed here that the research is limited in its scope to purely personal psychological factors for investigation. There is no use of social factors in the creation of this model. The methodology banks on the use of AISEQ in order to gauge the direct and indirect effects of different factors on the rehabilitation process. This indicates that the model being created is limited in its scope to the main rehabilitation methods it relies on (self-efficacy and imagery). Results from this research indicated that task efficacy was more dominantly related to rehabilitation than coping efficacy. On another note, the research also indicated that cognitive and motivational imagery was able to produce better results than motivational imagery (Milne et al., 2005). The results of this research and the ensuing coping model indicate that this model is limited to personal factors only in the rehabilitation process. However, this is not reflective of the actual situation as indicated by the biopsychosocial model. In addition other research on the issue has also pointed to the relevance of social factors in rehabilitation after a sports injury and the ensuing return to sports (Albinson & Petrie, 2003) (Gallagher & Gardner, 2007) (Johnson, 2000). It can alternatively be argued that social factors ultimately affect the athlete on a personal level through psychological domains. This position seems reasonable but research indicates the need to disentangle social factors from emotional and personal factors in order to produce more predictive models (Podlog & Eklund, 2006). Another model that has emerged in recent years is the self-determination theoretical (SDT) framework which can be seen as a reaction to the biopsychosocial model. This model aims to improve upon the existing deficiencies in the biopsychosocial model and the stages of return to sports models. However, this does not indicate that this model is limited to the two models mentioned above alone. The SDT model also accommodates some other factors along with the factors delineated by the biopsychosocial model and the stages of return to sports models. The work by Podlog et. al. (2007) can be seen as critical to delineating a practical model for sports injury rehabilitation based on SDT. Research on psychological difficulties in returning to sports after injury indicates that three critical areas must be looked into namely competency, autonomy and relatedness. Since SDT is itself highly concentrated on these these areas so it was theorised that SDT could be used as a competent model to deal with rehabilitation after sports injury. However, it must be kept in mind here that the use of SDT as a model for sports injury rehabilitation is limited inherently due to the focus of such a model on psychological reasons alone. The inherent limitation of this model stems from its very structure though it must be related that the model is otherwise sturdy for psychological barrier assessment and solution provision. The SDT model holds that human beings require motivation in order to achieve things in life such as re-joining sporting activities after injury. This motivation is derived in common from a combination of two paths – internal motivation paths and external motivation paths. Internal motivation paths are regulated by the individual themselves while the effects of the external motivation paths differ from individual to individual. This can be explained better in terms of people with greater regard to external factors and influences compared to people with lower regard to external factors and influences. The balance between the internal motivation paths and the external motivation paths is therefore the sum total of both paths and tends to vary from one person to the other. However, there are some commonalities that are associated to this method of motivation. The motivation derived from these paths is used to bolster three psychological perspectives delineated above – competence, autonomy and relatedness. This contention is also supported by other research on the matter (Ryan & Deci, 2000). This model clearly suggests that if an athlete is able to address these three levels of issues (competence, autonomy and relatedness) through internal and external motivation, then a successful return to sports is actually possible. Additionally, it must be related that the successful return to sports means that the athlete can meet or exceed pre-injury performance levels. In addition to the models presented above, other models and theories have been postulated as well such as the conceptual model by Taylor and Taylor (1997). The presented model has remained stagnant over the years and has received little attention from the research community which limits any check of its efficacy. The lack of empirical evaluation of this model and other like it means that there is little credibility available to these models. In a similar manner an older model better known as the stress and injury antecedent model (Andersen & Williams, 1988) has received little empirical evaluation rendering it useless over the decades. The current models presented for sports injury rehabilitation are also in danger of losing credibility given a lack of research though the situation is not as bad as previously. It has been suggested that research on the biopsychosocial model is promising (Andersen, 2001) and may provide a holistic model though constant addition and revisions of the model. Based on the models presented above, it is apparent that no one model is able to deal with the issue of rehabilitation after sports injury. The holistic models presented in the beginning are limited in some respects so they cannot be used wholly to deal with athlete rehabilitation after sports injury. On the other hand the non-holistic models are limited by their inherent structure such as by their narrowed focus on one aspect of solutions such as psychology. Extant research on the issue of returning to sporting activities after facing a sports injury indicates that self-efficacy, goals and expectations as well as environmental factors all play their part in determining the successful outcome of efforts. Here it could be said that while any one model fails to accommodate for these factors holistically, but these models put together would produce a better and more predictive model. This transition can be helped out by the commonalities in most of these models as well as by researching the gaps to fill in the missing information. The biopsychosocial model tends to provide very fertile ground in this regard as it accommodates biological (or physical), social as well as psychological factors involved in rehabilitating injured athletes. It would be advisable to take current research on athlete injury rehabilitation models to the next level by banking on the biopsychosocial model through expansion by related research. References Albinson, C.B. & Petrie, T.A., 2003. Cognitive appraisals, stress and coping: Preinjury and postinjury factors influencing psychological adjustment to sport injury. Journal of Sport Rehabilitation, 12, pp.306-22. Andersen, M.B., 2001. Returning to action and the prevention of future injury. In J. Crossman, ed. Coping with sports injuries: Psychological strategies for rehabilitation. Melbourne: Oxford University Press. p.162–173. Andersen, M.B. & Williams, J.M., 1988. A model of stress and athletic injuries: Prediction and prevention. Journal of Sport and Exercise Psychology, 10, p.294–306. Apter, M.J., 1982. The experience of motivation: The experience of psychological reversals. London: Academic Press. Bandura, A., 1997. Self-efficacy: The exercise of control. New York: Freeman. Brewer, B.W., 1993. Self-identity and specific vulnerability to depressed mood. Journal of Personality, 61, pp.343-64. 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. Morgantown, WV: Fitness Information Technology. pp.41-54. Brewer, B.W. et al., 2004. Rehabilitation adherence and anterior cruciate ligament outcomes. Psychology, Health and Medicine, 9, pp.163-75. Brewer, B.W. et al., 2000. Attributions for recovery and adherence to rehabilitation following anterior cruciate ligament reconstruction: A prospective analysis. Psychology and Health, 15, pp.283-91. Carson, F. & Polman, R.C.J., 2008. ACL injury rehabilitation: A psychological case-study of a professional rugby union player. Journal of Clinical Sport Psychology, 2, pp.71-90. Cupal, D.D. & Brewer, B.W., 2001. Effects of relaxation and guided imagery on knee strength, reinjury anxiety, and pain following anterior cruciate ligament reconstruction. Rehabilitation Psychology, 46, pp.28-43. Gallagher, B.V. & Gardner, F.L., 2007. An examination of the relationship between early maladaptive schemas, coping, and emotional response to athletic injury. Journal of Clinical Sport Psychology, 1, pp.47-67. Johnson, U., 2000. Short-term psychological intervention: A study of long-term injured competitive athletes. Journal of Sport Rehabilitation, 9, pp.207-18. Kubler-Ross, E., 1969. On death and dying. London: Tavistock. Lazarus, R.S., 2000. How emotions influence performance in competitive sports. The Sport Psychologist, 14, pp.229-52. Maehr, M.L. & Braskamp, L.A., 1986. The motivation factor: A theory of personal investment. Lexington, MA: D.C. Heath and Company. Mankad, A., Gordon, S. & Wallman, K., 2009. Perceptions of emotional climate among injured athletes. Journal of Clinical Sport Psychology, 3, pp.1-14. Milne, M.I., Hall, C.R. & Forwell, L., 2005. Self-Efficacy, Imagery Use, and Adherence to Rehabilitation by Injured Athletes. Journal of Sports Rehabilitation, 14(2), pp.150-66. Podlog, L. & Eklund, R.C., 2006. A longitudinal investigation of competitive athletes' return to sport following serious injury. Journal of Applied Sport Psychology, 18, pp.48-68. Podlog, L. & Eklund, R.C., 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, pp.535-66. Rogers, R.W., 1975. A protection motivation theory of feat appeals and attitude change. Journal of Psychology, 91, pp.93-114. Ryan, R. & Deci, E.L., 2000. Self-determination theory and the facilitation of intrinsic motivation, social development and well-being. American Psychologist, 55, pp.68-78. Smith, A.M., Scott, S.G., O'Fallon, W.M. & Young, M.L., 1990. Emotional responses of athletes to injury. Mayo Clinic Proceedings, 65, pp.38-50. Taylor, J. & Taylor, S., 1997. Psychological approaches to sport injury rehabilitation. Gaithersburg, MD: Aspen. Tripp, D.A. et al., 2007. Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year postinjury. Rehabilitation Psychology, 52, pp.74-81. Wadey, R. & Evans, L., 2010. Working with Injured Athletes: Research and Practice. In S. Hanton & S.D. Mellalieu, eds. Professional Practice in Sport Psychology: A Review. London: Routledge. pp.1-42. Wiese-Bjornstal, D.M., Smith, A.M., Shaffer, S.M. & Morrey, M.A., 1998. An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10, pp.46-69. Read More