Background Psychological factors have been shown to be associated with the recovery and rehabilitation period following sports injury, but less is known about the psychological response associated with returning to sport after injury. The aim of this review was to identify psychological factors associated with returning to sport following sports injury evaluated with the self-determination theory framework.
Study design Systematic review.
Method Electronic databases were searched from the earliest possible entry to March 2012. Quantitative studies were reviewed that included athletes who had sustained an athletic injury, reported the return to sport rate and measured at least one psychological variable. The risk of bias in each study was appraised with a quality checklist.
Results Eleven studies that evaluated 983 athletes and 15 psychological factors were included for review. The three central elements of self-determination theory—autonomy, competence and relatedness were found to be related to returning to sport following injury. Positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly. Fear was a prominent emotional response at the time of returning to sport despite the fact that overall emotions became more positive as recovery and rehabilitation progressed.
Conclusions There is preliminary evidence that positive psychological responses are associated with a higher rate of returning to sport following athletic injury, and should be taken into account by clinicians during rehabilitation.
- Sport and exercise psychology
- Sporting injuries
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Athletic injury has been associated with negative psychological responses. These include tension, low self-esteem and emotions such as depression and anxiety1 immediately following injury and during rehabilitation. Additionally, an athlete's ability to cope with stress while injured has also been shown to influence recovery and progression through a rehabilitation programme.2 Negative psychological responses have also been reported to occur at the time the athlete receives clearance to return to sports participation.3
Psychological responses change as the athlete progresses through the rehabilitation phase.3 Morrey et al3 showed a U-shaped emotional response pattern where negative responses predominated immediately following injury, subsided as rehabilitation progressed, then became prominent again at the time the athlete received medical clearance to return to sport. Maladaptive psychological responses may be detrimental to the athlete's ability to return to their previous level of sports participation and may also affect the quality of sports performance, and increase the risk of reinjury.4–8 Given the change in psychological responses throughout rehabilitation and the fact that returning to sport is the main criterion by which a successful outcome is judged, investigation of the effect of psychological responses on whether athletes successfully return to sport is important.
Podlog and Eklund9 identified motivation as a key factor likely to influence the transition back to sport following injury. Their extensive narrative review examined psychological factors within the framework of self-determination theory.10 Their review highlighted the paucity of empirical research examining the return to sport phase following athletic injury and the psychological factors influencing this transition, particularly when compared with the extant literature examining the psychological factors manifesting in earlier phases of recovery.9 Self-determination theory emphasises three innate psychological needs—autonomy, competence and relatedness which when fulfilled, enhance self-motivation and healthy psychological development.10 Autonomy pertains to psychological factors (eg, motivation) that promote in the athlete a perception that their behaviour is self-authored or personally endorsed.9 Competence pertains to the cognitive and emotional responses (eg, fear and confidence) that contribute to an athlete's perception of their proficiency or effectiveness in sports participation. Relatedness pertains to an athlete's perception of connectedness or belonging in a social context. With respect to returning to sport, the self-determination theory provides a framework within which to identify and organise the psychological factors that influence successful return to sport. When the autonomy, competence and relatedness needs are fulfilled it is proposed that the chance of successfully returning to sport is maximised.
The current review aimed to build upon the important work of Podlog and Eklund9 by employing systematic review methods to review the psychological factors associated with returning to sport following sports injury. Self-determination theory was applied to this review to assist the synthesis of psychological factors. Returning to sport was defined for the purpose of the current review as a distinct phase of the recovery process—the time between receiving medical clearance to return to sport and actually returning to play.
Relevant articles were identified via a search of the following electronic databases: MEDLINE, PsychInfo, SPORTDiscus, Embase, CINAHL, AMED, The Cochrane Library and PEDro. All databases were searched from the earliest possible entry (January 1948 for Medline) to March 2012 (see supplementary Appendix SA for the search strategy as applied to the Medline database). Search terms were mapped to relevant MeSH terms or subject headings where possible. Search terms were entered into each database under three concepts: (1) athlete, injury and athletic injuries; (2) biopsychosocial, psychosocial, psychological techniques, health knowledge, illness beliefs, recovery expectation, attitude to health, locus of control, anxiety, depression, self-efficacy, fear, kinesiophobia, confidence, motivation, fear of re-injury, fear for re-injury, coping behaviour and sport psychology and (3) return to sport, sport re-entry, return to play, sport competition and athletic participation.
Keywords in each concept were grouped with the OR operator. The results from each concept were then combined with the AND operator to produce the search strategy. The reference lists of relevant papers were manually searched and forward citation tracking was undertaken via the electronic database Web of Science.
The selection criteria are presented in table 1. Participants must have sustained an injury during participation in sport. Studies were required to have reported return to sport data so it was possible to distinguish between participants who specifically returned to sport and those who returned to physical activity, as the psychological response may differ. Only studies reporting quantitative data were sought as this review aimed to provide empirical evidence regarding the psychological responses associated with returning to sport. When applying the selection criteria, the title and abstract of each study were first reviewed. Where it was unclear from the title and abstract whether a study was appropriate for inclusion, the full text of the article was obtained for review. Two reviewers applied the selection criteria independently. Consensus was used to resolve any disagreements between reviewers. A third reviewer was consulted if consensus was not achieved.
Assessment of risk of bias
The risk of bias in all studies included in this review was assessed using a checklist adapted from Williamson et al11 The checklist comprised three sections: study characteristics (items 1–9), outcome measures (items 10–13) and prognostic factors studied and results (items 14–17; see supplementary Appendix SB for a full description of items and instructions for scoring) that are scored as satisfactory or unsatisfactory. Studies with a low risk of bias scored ≥75% for all sections, moderate risk-of-bias studies scored at least 50% for all sections and studies with a high risk of bias scored below 50% for any one section.11 Two reviewers completed the assessment of risk of bias independently. Discrepancies were resolved by discussion or consensus with a third reviewer when agreement could not be reached. Studies were not excluded on the basis of risk of bias.
Data extraction and synthesis
Reporting for the current systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines.12 Data were obtained using a data extraction form developed specifically for this review. Data were sought for the following variables: participant number, age and sex; injury type; time from injury to follow-up; return to sport rate (%) and psychological factors evaluated. The primary outcome of interest was the association between the psychological variable(s) reported and return to sport. Descriptive statistics were calculated for demographic data including age, time from injury to follow-up and return to sport rate. Effect sizes (Cohen's d) and risk ratios (where appropriate) were calculated for comparison of results between returned-to-sport and not-returned-to-sport groups. Due to the heterogeneity of the included studies a meta-analysis was not performed and data were synthesised descriptively using self-determination theory as a framework.
The electronic database search yielded a total of 1815 references, and a further eight references were identified via citation tracking. Following deletion of duplicates and deletion of studies based on title and abstract, 45 full-text articles were obtained for further review. In total 34 of the 45 full text articles obtained were excluded (see supplementary Appendix SC for full references and reasons for exclusion), leaving 11 articles included for full review (figure 1). Additional information was sought from authors about whether all participants were participating in sport before injury,13 and whether all participants returned to regular sports participation postoperatively.14–18
Assessment of risk of bias
The results of the assessment of risk of bias are presented in table 2. Overall, the number of items satisfied by each study ranged from 4 to 13 (out of a possible 17). Ten of the 11 studies,14–16 18–24 were rated as having a high risk of bias. One study was rated as having a moderate risk of bias.25 One study undertook blinding of participants or assessors.25 There were three studies where the psychological factors investigated were fully described,15 ,21 ,25 and three studies where it was possible to ascertain that the loss to follow-up was less than 20%.21 ,22 ,25 There was also only one study where the treatment participants received was fully described.22
The 11 studies reviewed reported on a total of 983 injured athletes (of which 654 (67%) were men) with a mean age of 24.4 years (range=12–54 years; table 3). The athletes ranged from international level to recreational level. Three studies reported outcomes following anterior cruciate ligament (ACL) reconstruction surgery.20 ,22 ,24 Seven studies did not describe the specific types or frequencies of injuries sustained by their participants. The 11 studies reported a pooled rate of return to the athletes’ preinjury level of sports participation of 82% (range=40–100%).
There were 18 different outcome measures used to assess 15 different psychological factors related to returning to sport (for full description see supplementary Appendices SD and SE). Four studies reported on the development of new scales to evaluate return to sport psychological outcomes.16 ,19 ,20 ,24 All but two studies18 ,20 reported evidence of the psychometric properties of the outcome measures used, with adequate-to-excellent internal consistency being reported for all outcome measures.
Athletes who returned to sport following ACL reconstruction surgery had significantly greater preoperative motivation than athletes who did not return to sport (table 4).20 Following a return to sport, athletes with more positive perceptions of their return to sport (measured with the Return to Sport after Injury Questionnaire (RSSIQ)) were shown to have greater intrinsic motivation (β=0.365, p=0.001), and those with more negative perceptions of their return to sport were shown to have greater extrinsic motivation (β=0.258, p=0.013).16 Athletes’ self-esteem (measured using the Rosenberg Self-Esteem Inventory) did not change from preinjury levels.25
In a group of athletes who had returned to sport, those who had more positive perceptions of their return to sport outcomes (measured with the RSSIQ) reported a greater sense of autonomy needs satisfaction as indicated by a significant positive correlation between well-being and the autonomy subscale of the Needs Satisfaction Scale (r statistic range=0.19–0.28; p<0.05).15
The following competence factors were identified in the included studies: confidence,19 ,22 ,24 emotions,18 ,22–24 mood,14 ,19 ,21 ,23 ,25 perception of negative influence of injury on current life situation,21 psychological readiness to return to sport,19 risk appraisal,22 ,24 subjective estimation of injury severity14 and competence needs satisfaction.15
Athletes who had returned to sport scored significantly higher on the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) when compared with athletes who had not returned to sport following ACL reconstruction surgery (table 4), demonstrating a significantly more positive psychological response (greater confidence, positive emotions and positive risk appraisal).22 ,24 The ACL-RSI (F2,170=16.47, p<0.001) and Injury Psychological Readiness to Return to Sport scale (I-PRRS) scores (F1,21=68.26, p<0.001) became more positive over time indicating confidence, emotions, risk appraisal and psychological readiness to return to sport became more positive throughout the recovery phase.19 ,22
Reports of the positive emotions of joy and excitement significantly increased (Cochrane's Q=28.56 and 30.06, respectively, p<0.05) and reports of negative emotions anger and disgust simultaneously decreased (Q=29.42 and 15.42, respectively, p<0.05) as athletes progressed through rehabilitation and returned to sport.18 Reports of fear significantly increased when athletes returned to competition (Q=8.0, p<0.05) compared with during rehabilitation. At the time of returning to competition, fear was reported by approximately 40% of athletes, compared with approximately 13% during rehabilitation.18 Athletes who had less fear of relapse of injury (measured using the fear subscale of the Subjective Injury Estimation Questionnaire) returned to sport more quickly after receiving medical clearance (r=0.64; p<0.05).14 Emotional Responses of Athletes to Injury Questionnaire (ERAIQ) scores also became more positive over time (F1,21=5.79, p=0.005).22 There was no difference in ERAIQ) score between athletes who had and had not returned to sport following ACL reconstruction surgery (table 4).22
In a group of athletes who all returned to sport, injury severity was found to predict postinjury depression (measured using the POMS) (F1,34=8.48; R2=0.3; p=0.0063).25 Mood became significantly more positive with increasing time from injury (χ²=12.17, p=0.002;14 F1,21=27.98, p<0.001;19 at 4 weeks postinjury: F=3.53, p=0.019; at 6 weeks postinjury: F=4.74, p=0.04),23 and was significantly negatively correlated with I-PRRS scores indicating that mood became more positive as psychological readiness to return to sport increased (r statistic range: −0.78 to −0.57, p<0.01).19 Once the athlete received medical clearance to return to sport, the degree of mood tension (measured using the Profile of Mood States (POMS)) was significantly related to the time taken to return to sport (r=0.52; p<0.05).14 Lower hedonic tone (the ability to experience pleasure or satisfaction) was the only mood state that was found to contribute to the prediction of not returning to sport (OR=29.73). The six-variable multiple logistic regression model (χ2=20.1, df=6, p=0.003, correctly predicted cases=96.1%)21 suggested that female sex, not setting rehabilitation goals, negative outlook regarding injury and negative attitude toward rehabilitation (as assessed by the treating therapist) along with hedonic tone were predictive of an athlete who was not likely to return to sport.21
Athletes’ estimation (measured with the Subjective Injury Estimation Questionnaire) of the severity of their injury (r=0.60, p<0.05) and perceived interference with short-term expectations for recovery (r=0.63, p<0.05) were significantly associated with the time required to return to sport.14
Athletes who did not return to sport following completion of active rehabilitation perceived a more negative influence of their injury on their life situation. Risk ratio analysis demonstrated athletes who did not return to sport viewed their life situation over three times more negatively when compared with athletes who returned to sport (table 4).21
In a group of athletes who had returned to sport, those who had more positive perceptions of their return to sport outcomes (measured with the RSSIQ) reported a greater sense of competence needs satisfaction (indicated by a significant positive correlation between well-being and the competence subscale of the Needs Satisfaction Scale; r statistic range=0.20–0.25; p<0.01).15
A single relatedness factor was identified.15 In a group of athletes who had returned to sport, those who had more positive perceptions of their return to sport outcomes (measured with the RSSIQ) reported a greater sense of relatedness needs satisfaction (indicated by significant correlations between well-being and the relatedness subscale of the Needs Satisfaction Scale; r statistic range=–0.15 to –0.17 (negative affect), 0.20–0.21 (self-esteem and vitality); p<0.05).15
Coping mechanisms (measured with the General Coping Questionnaire) and personality factors such as anxiety, social desirability, impulsiveness and monotony avoidance (measured with the Karolinska Scales of Personality) were not found to relate to returning to sport following injury.21
The empirical evidence presented in this systematic review supports the previous qualitative and theoretical proposals that psychological factors are important influences on an athlete returning to sport. Overall, this review found preliminary evidence that positive psychological responses were associated with a higher return to sport rate after injury, a faster return and a greater likelihood of returning to the preinjury participation level. The results of this review suggest that psychological factors should be important considerations for treating clinicians during rehabilitation and return to sport. However, the high risk of bias identified in all but one of the included studies highlights the need for further exploration of the relationship between psychological factors and returning to sport.9
The current review included eight14 ,15 ,19–22 ,24 ,25 studies that were not reviewed by Podlog and Eklund.9 The results of these studies are in agreement with the findings of Podlog and Eklund9 that psychological factors associated with satisfying autonomy, competence and relatedness needs are important influences on successful return to sport.9 The findings of the current review are also consistent with previous qualitative literature that has investigated the psychological factors that athletes attribute to being associated with successfully returning to sport,26 ,27 and with quantitative literature that has investigated the factors associated with recovery and rehabilitation from injury.28–30 As athletes progress through the rehabilitation phase towards a return to sport, they describe a lessening of the negative emotions associated with sustaining the initial injury (such as depression, anger and anxiety), and a shift towards a predominance of positive emotions (such as confidence and readiness to return to sport), provided the period of rehabilitation has progressed as anticipated.
Fear remains a prominent emotion at the time athletes are actually returning to sport. This is consistent with qualitative literature.9 ,26 Fear is also a common reason given by athletes for not returning to sport.13 ,31 The prominence of fear has important clinical implications and suggests that the time of transition to back to full sports participation should be monitored closely to ensure the athlete feels adequately supported in their return to sport. Building the athlete's confidence in the injured body part particularly with the use of goal setting strategies regarding returning to sport may assist the return to sport transition.32 Importantly, athletes who perceive themselves as having made a successful return reportedly describe an associated dissipation of this fear upon testing the injured body part by returning to play.26 This is consistent with another finding of this review, that positive psychological responses are associated with positive perceptions of the return to sport outcome.15 ,16 ,19
Self-determination theory provides a framework, which specifically focuses on returning to sport, and accounts for individual differences in psychological responses, to assist the clinician to identify and subsequently address maladaptive psychological responses that may place the athlete at risk of not returning to sport. Factors for clinicians to consider, informed by self-determination theory include whether the athlete perceives they are in control of their return to sport, how they feel about returning to sport and whether they perceive support from coaches, team-mates and other significant individuals as they are returning to sport. Reducing athletes’ perceptions of external pressure to return to sport, by involving them in the identification of a realistic date for a potential return to sport, may promote a sense of autonomy. The use of goal setting and visual imagery throughout the active rehabilitation period to build confidence and self-esteem may promote a sense of competence. Improvements in confidence may also be achieved via strong social support which at the same time may assist in easing athlete fears about overstressing the recovered body part, setting realistic performance expectations and recognising improvements.33 ,34 A negative outlook regarding injury and a negative attitude toward rehabilitation were found to be predictive of not returning to sport.21 Clinicians may consider screening athletes during the rehabilitation phase to identify those with potentially maladaptive psychological responses to injury and implement strategies to address these issues. Screening could include psychological factors that were identified consistently in this review as being associated with returning to sport. For example, measures of motivation (autonomy), confidence and fear (competence) should be considered. An example of an appropriate psychological screening tool for patients returning to sport after ACL reconstruction is the ACL-RSI.22 ,24
The psychological responses of patients following ACL injury have been quantitatively evaluated in a number of studies.13 ,17 ,20 ,22 ,24 ,30 ,35–37 This potentially allows for a homogeneous population in terms of the type of injury to be studied where the injury is serious, significant and results in an extended absence from physical activity. However, some of these studies have not specifically studied homogeneous populations of athletes, or reported specifically on return to sport (return to participation in physical activity was reported), and were therefore not included in the current review.13 ,17 ,30 ,36 ,37 Nevertheless, the results of these excluded studies were consistent with the findings of the current review, in that more positive psychological responses were associated with a successful return to participation. Of particular note is the study conducted by Tripp et al17 where it was found that fear of reinjury was a unique predictor of return to sport in recreational athletes following ACL reconstruction. However, as the total proportion of athletes who returned to sport was not reported, this study was not included in the current review.
The athletes studied in the current review ranged from professional to recreational level athletes. To our knowledge, there are no studies directly comparing the psychological responses to injury of groups of athletes participating in differing levels of competition. However, it has been shown that athletes who are more involved in sport prior to their injury have higher confusion and perceive their recovery to be less at the end of their rehabilitation suggesting that emotional disturbance may be higher in athletes who invest more time in sport.38 Professional or elite-level athletes who derive financial benefit from their participation in sport may perceive additional pressure to return to sport. In previous studies athletes have reported feeling pressure to maintain their spot on the team, not let team-mates or coaches down by not playing,33 and concerns about being able to perform at their preinjury level upon return from injury.2 This perceived pressure may lead to an athlete returning to sport prematurely, before they are psychologically ready to do so, which has been shown to subsequently increase the likelihood of reinjury.33 It is also important to consider that athletes who do not return to their preinjury level may require additional support to cope with the associated lifestyle adjustment.39 ,40
Injury severity may also be a confounding factor when examining return to sport. Athletes with more severe injuries may exhibit more prolonged and severe negative psychological responses,18 ,26 ,41 ,42 which may carry over to the return to sport phase. This knowledge may assist clinicians to prioritise the interventions provided for specific athletes to maximise clinical and return to sport outcomes.
One of the strengths of this current review is that it applied strict inclusion criteria to enable evidence to be generated that was applicable specifically to athletes. In addition, the PRISMA guidelines for reporting in systematic reviews12 were also followed. There is a growing body of literature examining the relationships between psychological factors and returning to sport following injury. However, the fact that only 11 published studies met the inclusion criteria for this review, suggests that ongoing research is required. It is important that future research employs prospective designs with clearly defined athletic populations, and uses valid population-specific outcome measures with established psychometric properties to further investigate the psychological factors associated with returning to sport after injury. The current review only included one prognostic study, which demonstrated evidence of a predictive relationship between positive psychological responses and returning to sport.23 Prospective studies allow the identification of potentially prognostic psychological factors and their association with returning to sport.43 This may facilitate more accurate prediction of return to sport outcome on the basis of psychological responses, and allow athletes at risk of not returning to sport to be identified early based on their psychological responses.44
Empirical evidence suggests that psychological factors are likely to be important determinants of successful return to sport following injury. Positive psychological responses appear to promote a greater likelihood of the athlete returning to their preinjury level of participation and returning to sport more quickly. Fear was identified as a prominent emotional response at the time of transition back to sport, and clinicians should be prepared to address this and other autonomy and competence-related psychological factors early in the rehabilitation phase with confidence-building strategies such as goal setting. Clinicians may consider routine screening of injured athletes during the rehabilitation phase with validated and condition-specific measures to identify those at risk of developing maladaptive psychological responses.
What this study adds
This review synthesises evidence about psychological factors associated with returning to sport following injury. Most previous work has focused on the factors associated with injury occurrence and the active rehabilitation phase.
This review has shown preliminary evidence that an athlete's psychological response to injury despite becoming more positive with time, is likely to be an important influence on their likelihood of returning to sport.
The psychological response of athletes is an important consideration for the treating clinician rehabilitation to maximise athletes’ ability to successfully return to sport.
Contributors CA, NT and KW contributed to the conception and design of the review. CA applied the search strategy, extracted and analysed the data and wrote the manuscript and is responsible for the overall content as guarantor. CA and KW applied inclusion criteria. NT, JF and KW critically revised the manuscript for important intellectual content.
Competing interest None.
Provenance and peer review Not commissioned; externally peer reviewed.
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