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Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: a mixed studies systematic review
  1. Dale Forsdyke1,
  2. Andy Smith2,
  3. Michelle Jones3,
  4. Adam Gledhill4
  1. 1Applied Human Sciences Department, Faculty of Health and Life Sciences, York St John University, York, UK
  2. 2Faculty of Health and Life Sciences, York St John University, York, UK
  3. 3School of Sport, Health, and Social Sciences, Southampton Solent University, Southampton, UK
  4. 4School of Clinical and Applied Science, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds, UK
  1. Correspondence to Dale Forsdyke, Applied Human Sciences Department, Faculty of Health and Life Sciences, York St John University, Lord Mayors Walk, York YO31 7EX, UK; d.forsdyke{at}yorksj.ac.uk

Abstract

Background The prime focus of research on sports injury has been on physical factors. This is despite our understanding that when an athlete sustains an injury it has psychosocial as well as physical impacts. Psychosocial factors have been suggested as prognostic influences on the outcomes of rehabilitation. The aim of this work was to address the question: are psychosocial factors associated with sports injury rehabilitation outcomes in competitive athletes?

Study design Mixed studies systematic review (PROSPERO reg.CRD42014008667).

Method Electronic database and bibliographic searching was undertaken from the earliest entry until 1 June 2015. Studies that included injured competitive athletes, psychosocial factors and a sports injury rehabilitation outcome were reviewed by the authors. A quality appraisal of the studies was undertaken to establish the risk of reporting bias.

Results 25 studies were evaluated that included 942 injured competitive athletes were appraised and synthesised. Twenty studies had not been included in previous reviews. The mean methodological quality of the studies was 59% (moderate risk of reporting bias). Convergent thematic analysis uncovered three core themes across the studies: (1) emotion associated with rehabilitation outcomes; (2) cognitions associated with rehabilitation outcomes; and (3) behaviours associated with rehabilitation outcomes. Injury and performance-related fears, anxiety and confidence were associated with rehabilitation outcomes. There is gender-related, age-related and injury-related bias in the reviewed literature.

Conclusions Psychosocial factors were associated with a range of sports injury rehabilitation outcomes. Practitioners need to recognise that an injured athlete's thoughts, feelings and actions may influence the outcome of rehabilitation.

  • Injury
  • Review
  • Sports

https://doi.org/10.1136/bjsports-2015-094850

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    Introduction

    The prime focus of research on sports injuries has been on physical factors.1 This is despite our understanding that when an athlete sustains a sports injury it has psychosocial impacts.2 ,3 A common assumption has been that physical and psychosocial recovery occurs at the same time. Recently, it has been recognised that physical and psychological readiness to return to sport after injury do not always coincide.4 This means that athletes may return to training and competition when they are physically but not psychologically ready.

    Many athletes do not return to their preinjury level of activity, and even less return to competition.5 ,6 Competitive athletes may be less likely to return to a preinjury level of performance than recreational athletes.6 As rehabilitation takes place within social contexts involving many people, a key to effective rehabilitation may lie with psychosocial factors.7 Psychosocial factors can be described as ‘pertaining to the influence of social factors on an individual's mind or behaviour, and to the interrelation of behaviour and social factors’.8 These factors have been identified as being important prognostic influences in a range of sports pathologies.5 ,9–11

    Psychosocial factors are also present within a number of models that have been applied or developed within this area.2 ,12 ,13 These draw on stage-based, cognitive appraisal or biopsychosocial approaches and give a conceptual framework to work from, although no single approach predominates the evidence.4

    Three major systematic reviews have been published within this area.14–16 These have addressed the need for transparency, methodological rigour and non-biased perspectives in reporting the empirical evidence.17 Of the three reviews, two are exclusively focused on psychosocial factors influencing anterior cruciate ligament (ACL) rehabilitation.15 ,16 While ACL injury has high personal impact,18 this represents a narrow perspective and precludes any generalisation of the findings. To reduce injury-related bias there is a need to include other injuries which have the same prevalence, severity and chronicity (eg, high-grade lateral ankle sprain, rotator cuff tendinopathy). All of these reviews agree that psychosocial factors influence rehabilitation outcomes. However, differences in constructs were apparent across the reviews. Prominent factors highlighted in these reviews include motivation, self-efficacy, perceived control;15 autonomy, relatedness, competence;14 and affect, cognition, and behaviours.16

    These reviews report only quantitative research designs despite the existence of peer-reviewed qualitative empirical studies. Previous reviews that have excluded qualitative research have reduced the evidence on which they base their findings. There is recognition of the need for systematic methodologies to rigorously deal with diverse forms of evidence to address the disparity between academic research and practitioner experience.19 Integrating statistical generalisation with the in-depth description of complex phenomena gleaned from qualitative research has the potential to provide a detailed, rich and highly practical understanding of sport injury rehabilitation. Assessing the overall contribution of a body of literature with contrasting paradigms and designs can be more relevant to clinical decision-making.20

    The aim of this review was to examine the association between psychosocial factors and sports injury rehabilitation outcomes. This aim was underpinned by the research question: are psychosocial factors associated with sports injury rehabilitation outcomes in competitive athletes?

    Method

    The methodology of our systematic review was informed by the PRISMA guidelines17 and recommendations by Lloyd-Jones.21 We prospectively registered with PROSPERO in February 2014 (registration number: CRD42014008667), and our systematic review was granted ethical approval by the institutional ethics committee (ref: DF/08/09/2014/01).

    Search strategy

    Eight databases were searched on 1 June 2015 (ie, SPORTDiscus, CINAHL, AMED, MEDLINE, PsychINFO, SocIndex, PEDro, ScienceDirect) using multiple keywords and Boolean phrases (table 1). The search terms were agreed a priori and informed by breaking down the research question, relevant MeSH terms and by the biopsychosocial approaches used in the area.2 ,13 Extracted studies were included or excluded in a three-step screening process studying based on title, abstract and full text.21 We searched the reference lists of included studies using the same process.

    View this table:
    Table 1

    Search terms used for the systematic review

    Eligibility criteria

    The eligibility criteria are presented in table 2. There was no restriction on date of publication, gender, age or level of performance. Each study had to conform to best practice definitions of sports injury22 ,23 and competitive athlete, containing discernible psychosocial factors2 ,13 influencing sports injury rehabilitation outcomes.24 ,25 Studies of non-musculoskeletal (MSK) injury, such as concussion, were excluded based on specific psychopathology directly effecting neurocognitive function. It is difficult to separate out the psychological consequences associated with the injury pathology from the more interpretive psychosocial responses of athletes.26

    View this table:
    Table 2

    Eligibility criteria applied to studies

    Assessment of risk of bias

    To assess the methodological quality of the literature the mixed methods appraisal tool (MMAT) was used.20 Additional to generic criteria the MMAT has five sets of quality criteria relating to: (1) qualitative; (2) quantitative—randomised controlled studies; (3) quantitative—non-randomised controlled studies; (4) quantitative—observational descriptive studies and (5) mixed-methods studies. The overall quality score for each study was based on the methodological domain-specific criteria using a percentage-based calculation. Mixed methods studies were quality assessed within its own domain plus the domain/s used by its quantitative and qualitative components. According to the MMAT, for mixed methods studies the overall research quality cannot exceed the quality of its weakest component. The MMAT in this review was used to provide an informative description of overall quality and to assess the potential for bias in the findings. Literature using the MMAT has found that the consistency of the global ‘quality score’ between reviewers (ICC) was between 0.72 and 0.94.20

    Data synthesis

    The first step of data synthesis was indwelling,27 where the reviewers read the full text of each study and became immersed in the findings and inferences. Studies were then placed into three tables for the review (1) demographic characteristics, (2) study summary, (3) study quality appraisal. Convergent thematic analysis was used to synthesise data from different empirical findings and the assessment of methodological quality.28 A meta-aggregative approach was adopted. Meta-analysis was not conducted due to the heterogeneity within the included studies research designs.

    Establishing rigour

    To ensure rigour, a peer review team was formed. The team comprised of the lead researcher (DF), a professor from the same institution (AS) and an academic from another University (AG). This team was created to minimise bias and human error. Established methods of peer debrief and use of ‘devil's advocate’ were used to inform the reviews search strategy, records screening and generation of final themes from the included studies.27 The full text assessment of eligibility and quality appraisal was undertaken collaboratively in working meetings. These were chaired by the lead researcher with borderline cases or contentious issues resolved through group discussion until a consensus was reached. Eligibility of final studies was carried out using a voting system to determine the basis for study inclusion or exclusion. Decisions to include or exclude studies were based on majority voting. Where further clarification was deemed necessary, additional information was sought from study author(s) or referred to an appropriate university committee.

    Results

    Literature identification

    The electronic database search yielded 368 records. An additional 92 records were identified through systematic bibliographic searching (figure 1). Titles and abstracts of 432 records were screened following removal of duplicate records (n=28), and 368 records were excluded. We subsequently obtained and screened 64 studies in full text, and 39 were excluded. One study29 was referred by the team to the chair of the faculty's ethics committee for advice and later included. Finally 25 studies were included for systematic review (figure 1). Table 3 identifies the rating for each of the final studies as a marker of agreement for inclusion by the research team (eg, for full agreement three stars were awarded).

    View this table:
    Table 3

    Study quality appraisal

    Figure 1
    Figure 1

    Process overview of study identification, screening, eligibility and inclusion (adapted from Moher et al17).

    Assessment of risk of bias

    The methodological quality of included studies was assessed using the MMAT and decisions agreed by the team. Fourteen studies were assessed against qualitative criteria, five studies against quantitative (non-randomised) criteria, four studies against quantitative (descriptive) criteria, and two against mixed methods criteria (table 3). The methodological quality of the 25 studies varied between 25 and 75% (mean 59%). Qualitative studies scored highest for quality (mean 64%, range 25–75%), compared to quantitative studies (mean 55.5%, range 25–75%) and mixed methods (mean 37.5%, range 25–50%). Although the MMAT does not state specific thresholds for quality level it was agreed by the team in line with previous systematic reviews14 ,16 ,54 that there was a moderate to high risk of reporting bias.

    Demographic characteristics

    The 25 included studies reported on 942 injured athletes, aged 15–37 years (mean 23.7 years). Twenty-four studies reported the number of male and female participants. In total there were 552 (64%) men and 309 (36%) women. The athletes included in this review played team and individual sports, ranging from international levels of performance to regularly competing amateurs. The national affiliation of the study's lead author highlights the global interest in this topic (eg, Australia 44%, UK 24%, North America 20% and Scandinavia 12%).

    Study characteristics

    There were 14 qualitative, 9 quantitative and 2 mixed methods studies included in our review (table 4). Sports injury rehabilitation outcomes across the final studies focused on perceived and actual markers of physical and psychological rehabilitation (see online supplementary table S1). For example, return to sport,32 ,44 ,49 perceived success and effectiveness,31 ,36 ,46 and time loss from competition.35 Quantitative studies were correlation-based and utilised a wide range (n=22) of previously established inventories to measure psychosocial response, often with multiple inventories used simultaneously.31 ,34 ,41 ,43 Seven (32%) of the inventory measures used were specific to the sports injury domain.

    View this table:
    Table 4

    Demographic information from included studies

    There was a broad range of operational definitions of sports injury included across the included studies. Seventeen (68%) studies used a time loss-based definition, ranging from one day35 to two months.46 Where mean time loss was explicitly stated, this ranged from 18.5 days to 9.4 months.23 Return to competitive sport rates ranged from 51% to 78%.44 ,49 Injury characteristics revealed a bias towards serious knee injuries with eight studies of ACL injury (32%), and eight where serious knee sprains dominated the range of pathologies. Ten studies (40%) focused on injuries requiring surgical intervention; the remaining 15 studies (60%) included a mixture of injuries or information about whether surgical intervention was required or was not stated.

    Psychosocial factors

    There were three core themes across the studies: (1) injury-related emotion associated with rehabilitation outcomes (2) injury-related cognitions associated with rehabilitation outcomes and (3) injury-related behaviours associated with rehabilitation outcomes (table 5). The mean methodological quality of the themes ranged from 56.3% to 58.8%.

    View this table:
    Table 5

    thematic evaluation of the included studies (n=25)

    Injury-related emotion associated with sport injury rehabilitation outcomes

    Twenty studies had significant emotion-related (emotion, mood and affect factors) content. Specifically, the role of mood, anxiety and fear (re-injury and performance) and emotional integrity emerged.

    A number of studies found that as rehabilitation progressed toward a return to sport, total mood disruption (TMD) and total negative mood (TNM) decreased and more positive mood states developed.30 ,34 ,36 McDonald and Hardy30 in a study of five Division 1 athletes found a significant negative relationship between TMD and the outcome of athlete perceived rehabilitation (r=0.69, p≤0.0001).

    Despite return to sport often being seen as a positive rehabilitation outcome, a number of studies reported heightened levels of anxiety and/or fear during the transition.38 ,43 ,45 ,51 ,52 A frequently reported cause of anxieties and fear is that of re-injury.37 ,45 ,49 Performance-related anxiety and fear was prominent during the return to sport.36 ,38 ,52 ,50 Podlog and Eklund38 in a qualitative study of 12 athletes, all with severe injuries, found that successful rehabilitation was associated with effectively dealing with competition fears. Later work by the same author, on 11 injured elite adolescent athletes,51 highlighted the dual fears of pain and re-injury, together with the fear of falling behind others, missing out and underperforming. This suggests that fear is experienced by both adult and younger athletes.

    Three studies highlighted findings related to poor emotional integrity that is, finding athletes being reluctant to discuss their emotions about being injured with their sporting peers and coaches.36 ,39 ,45 Tracey36 found that when some athletes returned to sport their feelings of isolation/alienation remained. Mankad et al45 suggested that the inability to ‘emotionally disclose’ within the team environment was related to an impeded long-term psychological rehabilitation from sports injury.

    Injury-related cognitions associated with sport injury rehabilitation outcomes

    There were 18 studies that reached conclusions related to restoration of the self (self-confidence, self-esteem, self-identity), injury-related outlook, perceptions of basic psychological needs fulfilment and perceptions of growth and development were included. Injury-related cognitions appear to serve as ‘precursors’ to the resulting emotional responses (ie, nervousness, anxiety, excitement) and are associated with personal and situational factors.52 Personal factors such as gender, age, limited injury experience, lowered confidence and perceptions of isolation were all significantly related cognitions about not returning to sport. 32 ,37 ,44 ,49 Delayed surgical intervention was a noteworthy situational factor that was associated with negative risk appraisal and non-return to sport at 2–7 years post-ACL surgery.49

    Ten studies identified restoring the self as being important in the successful return to sport following injury.29 ,34 ,35 ,38 ,40 ,43–45 ,53 According to the reviewed studies restoring the self appears to be: (1) an important motivating factor, (2) a common concern when returning to sport following injury and (3) a predictor of time loss from sport due to injury.33 ,35 ,38 ,52

    Six studies identified that a successful return to sport was associated with feelings of sport-related self-confidence.29 ,34 ,44 ,43 ,50 ,53 Within this context sport-related confidence was relative to both injury and performance. Two studies by Carson and Polman43 ,50 found confidence-building was important in the return to sport with this developed from injury specific and performance specific inputs (eg, from fitness testing, performing well during activity and the injury site feeling ‘strong’). Podlog et al53 found confidence was a major attribute of psychological readiness to return to sport. Overall confidence in returning to sport was associated with the rehabilitation programme, the injured body part, and performance capability beliefs. ‘Precursors’ to developing confidence in returning to sport were noted as having trust in the rehabilitation provider, satisfaction of social support needs and achievement of physical standards/clinical outcomes. Langford et al44 used the ACL return to sport after injury scale (RSI) with injured athletes, and found a significant difference between the group of returners to sport and those that had not returned at 6 months (p=0.005) and 12 months (p=0.001).

    Six studies (24%) inferred that fulfilling basic psychological needs was an important predictor of successful return to sport. Of these, three studies were grounded in basic psychological needs theory55 and were published by the same author.38 ,46 ,51 The studies within this subset highlight the importance of addressing relatedness, competence and autonomy during reintegration into sporting activities in order to reduce TNM and to experience a successful rehabilitation.41 ,46 Notably, fulfilment of competence, relatedness and autonomy seems important in elite adult and adolescent populations.38 ,46 ,51

    Importantly, seven of the final studies (28%) suggested that perceiving injury as an opportunity for growth, and as a positive developmental experience was related to a successful rehabilitation.35 ,36 ,38 ,48 ,52

    Injury-related behaviour associated with sport injury rehabilitation outcomes

    Twelve studies (48%) contributed to this core theme relating to the effect of coping strategies, and social interactions on the athlete's rehabilitation outcomes.

    There was ambiguity in findings regarding which type of coping mechanism was related to positive rehabilitation outcomes. Avoidance focused coping strategies were suggested as being both facilitative47 and also debilitative.41 ,45 A mixed-method study47 of elite professional rugby players found that behavioural and cognitive avoidance coping strategies enhanced perceptions of recovery. In contrast two studies credited using avoidance coping with less successful rehabilitation outcomes such as a delay in psychological rehabilitation,45 and associated increase in TNM.41

    There was stronger agreement within the final studies about the positive association problem-focused coping strategies have with rehabilitation outcomes, such as reintegration back into training/competition.34 ,40 ,43 ,50 Gallagher and Gardner41 found that in the return to sport phase of rehabilitation there was a significant negative relationship between approach focused coping and TNM (r=−0.354, p≤0.05). Two studies by Carson and Polman43 ,50 identified problem-focused coping strategies enhanced the experience of returning to sport after an ACL injury

    Seven studies highlighted the importance of social interaction to perceived and actual rehabilitation outcomes. Perceptions of social support network provided by multiple agents (eg, team mates, medical staff, coach, family, crowd) were particularly salient on returning to sport.43 ,50 Trust in the rehabilitation provider, feeling wanted by others, and satisfaction of social support needs were associated with psychological readiness to return to sport.53 Insufficient social support appears to be associated with unsuccessful rehabilitation,32 and remains a common concern on returning to sport.36 ,51

    Discussion

    The aim of this review was to understand the association between psychosocial factors and sports injury rehabilitation outcomes. This aim was underpinned by the research question: are psychosocial factors associated with sports injury rehabilitation outcomes in competitive athletes? Of the 25 studies included in our review, 20 had not been included in previous reviews. Our findings suggest that psychosocial factors (emotion-related, cognition-related and behavior-related) are associated with a variety of perceived and actual rehabilitation outcomes. It is thought that this process is cyclical in nature.52 For example, cognitions impact on injury-related emotions and behaviours, and vice versa. Our findings are consistent with previous reviews and theoretical perspectives.2 ,13 ,16 ,56 However, what is not known is to what extent these psychosocial factors are related to rehabilitation outcomes; singularly or cumulatively, compared with biological factors.

    Other domain-related systematic reviews14–16 highlight fear of re-injury as one of the most common emotional factors associated with rehabilitation outcomes after severe injury. Fear is seen as a unitary construct within quantitative research designs that dominate previous reviews. In contrast, the evidence from this review highlights the fact that injured athletes experience many anxieties and fears during rehabilitation. Our findings suggest that the anxieties and fears athletes experience come in two forms: (1) re-injury related37 ,45 ,49 and (2) performance related.36 ,50 This knowledge may help inform psychological intervention during the rehabilitation of injured athletes.

    Evidence from our review and the broader literature suggests an association between rehabilitation outcomes and anxiety/fear of being re-injured.37 ,57 ,58 The athlete who can effectively manage anxiety and fear will experience more positive outcomes from rehabilitation.38 Ardern et al59 highlighted the concept of ‘psychological readiness’ as important in determining return to sport decisions following ACL injury. The construct of ‘psychological readiness’ in terms of sports injury can be interpreted as being a combination of the athlete experiencing low levels of fear regarding re-injury and underperforming.60

    Restoring self-confidence was a key subset emerging from the included studies.34 ,43 ,44 ,50 Self-confidence is derived from two elements: (1) confidence in the injury site and (2) confidence in performance. Confidence may have a moderating effect on the emotion of fear as both seem determined by injury and performance-related inputs. This review indicates that successful return to sport is underpinned by developing self-confidence cognitions, even though the mechanism of effect is not yet fully established.29 ,50 Confidence in returning to sport after injury appears to be a multidimensional factor.53 Developing confidence in the injured body part and in the ability to perform to a satisfactory standard may act as a ‘buffer’ from injury-related anxiety and fear. The implication of this is athletes would acquire the suitable ‘psychological readiness’ to return.

    Experiencing adversity has the potential to yield positive outcomes. Nonetheless, it is important to note that stress-related growth is not inevitable.61 An ability to perceive sport injury rehabilitation as an opportunity for development and growth was associated with more positive rehabilitation outcomes.35 ,48 A perspective from Wadey et al62 is that growth through adversity may even lead to ‘positive changes that propel them to a real or perceived higher level of functioning than that which existed prior to the negative circumstance’. It seems that perceiving the experience related to injury as positive may facilitate returning to sport,38 enable a more holistic recovery.48 Different forms of growth that can occur through injury include: personal, psychological, social and physical.62 Practitioners may consider encouraging athletes to reflect on the injury experience as an opportunity for growth to facilitate positive rehabilitation outcomes.

    Emotional integrity relates to the athletes conscious decision to either withhold or disclose false injury-related emotions, and emerged as an important subset. This may compound perceptions of isolation and impede psychological rehabilitation outcomes.36 ,39 ,45 Our findings support the theoretical propositions of Wiese-Bjornstal,13 whereby emotional integrity (or emotional inhibition as phrased in the model) is identified as an emotion-related factor associated with rehabilitation outcomes. The emotional integrity (or lack of) could have a profound effect on the ability to collect accurate data. A lack of emotional integrity may challenge the validity of some studies already published and challenges researchers to develop methodologies to overcome this problem. Both researchers and practitioners should give injured athletes the opportunity to use non-traditional forms of communication (eg, blogs and diaries).

    Current empirical limitations and future directions

    The empirical literature relating to adult male athletes with severe knee injury (eg, ACL) is well established. We conclude that this has created gender-related, age-related and injury-related biases in the literature, limiting generalisability of findings. Male and females have different physical and psychological responses to injury. This can lead to very different injury experiences and outcomes.63 ,64 Age-related differences is a neglected area in sport injury psychology.65 The fact that only one study included adolescent participants highlights this problem. Researchers and practitioners should be aware of the gender, age and injury differences across athletic populations to better facilitate positive rehabilitation outcomes.

    Most studies reviewed adopted the perspective that return to sport is the major rehabilitation outcome, and cease their data collection at this point.40 ,41 Return to play is often seen as the defining feature of recovery and has been criticised for skewing the evidence base.66 It is naïve to assume that just because an athlete returns to sport postinjury that they are fully recovered both physically and psychologically. It is plausible that the interpretation of a successful rehabilitation is associated with many complex biopsychosocial, technical and tactical factors. Therefore, using return to preinjury activity levels as the sole indicator may be too simplistic.

    Included studies lacked detail regarding comorbidity, multiple pathologies, iatrogenic issues or mis-diagnosis issues, despite these being potentially striking features of the injured athlete's experience.2 ,13 There appears to be little empirical literature on complicated, multipathological or unsuccessful rehabilitation. Studies using negative case analytical approaches could profoundly change our understanding of the area. For example, studying athletes that have had a complicated or unsuccessful rehabilitation.

    The bias towards non-experimental, correlational designs within the literature restricts the ability to establish causal relationships between psychosocial factors and injury rehabilitation outcomes. Owing to the nature of evidence reviewed a causal link between psychosocial factors and rehabilitation outcomes cannot be reliably inferred. In addition to exploring experiences of injured athletes, future research could also explore causal patterns.

    Strengths and limitations of this review

    There are methodological challenges in conducting a mixed studies systematic review.19 The tendency for systematic reviews to exclude non-experimental research has received criticism, particularly because it does not account very well for the local and experiential nature of a clinicians work.19 ,67 ,68

    There is a growing call for mixed study reviews within the healthcare sector to address the perceived divergence between research and practice.19 ,68 This review is a positive response to this call and therefore offers an important contribution to the literature. The reviewed quantitative evidence provides associations between psychosocial factors and rehabilitation outcomes. Additionally, the qualitative and mixed methods evidence elucidates mechanisms behind these associations, and how psychosocial factors are modified throughout the rehabilitation process. This review was focused on competitive athletes. Therefore, this precludes any robust generalisability to other populations such as recreational and intramural athletes or non-athletic patient groups. All levels of competitive athlete were included. It is plausible that athletes with more time investment in sport or those who gain financial benefit for participation may exhibit different types and/or intensity of psychosocial factors.14 Since we considered all published literature, there is a chance the results of older studies may not be generalisable to modern sports medicine practice. This review included all sports injury types to develop an understanding beyond simply ACL injury. It must be noted however, that the findings of this review are based on a sizeable percentage of postoperative ACL participants. Injury severity and type may be a confounding factor when examining sports injury rehabilitation outcomes.14 An athlete with more severe injuries may exhibit more prolonged and severe negative psychosocial responses proliferating into the return to sport phase. Including studies with mixed time loss is ecologically valid, however, by aggregating studies the ability to differentiate injury experiences across specific populations is diminished. For example, whether analogous psychosocial factors are associated with injuries requiring surgical versus non-surgical intervention could be debated.

    If injury outcomes are associated with psychosocial factors as this and other reviews suggest, practitioners need to be empowered to recognise and address these factors or appropriately refer on.69 ,70

    Conclusion

    We found that the athlete's injury-related cognitions, emotions and behaviours were associated with sports injury rehabilitation outcomes. Restoring self-confidence, while at the same time inoculating against emotions of anxiety/fear appears to increase the likelihood of a successful rehabilitation. Meeting social support needs and employing appropriate coping strategies appears important in facilitating this. It seems common for athletes not to fully disclose their injury-related emotions. Practitioners should consider approaches to improve an athlete's emotional integrity and regularly monitor psychosocial factors throughout rehabilitation. The injury experience can be an opportunity for growth and development. Practitioners should enable their athletes to perceive the injury experience as positive, as this is related to positive outcomes.

    What are the findings?

    • Psychosocial factors including how an athlete thinks, feels and acts are associated with the outcomes of rehabilitation.

    • An athlete's psychological readiness to return to play appears to be a product of fear, anxiety, confidence in performing well and remaining uninjured.

    • Being female, young, having a limited experience of injury, negative emotion and perceptions of isolation are factors related to less successful outcomes of rehabilitation.

    • Our current interpretation of a successful rehabilitation is overly simplistic and associated with many biopsychosocial, technical and tactical factors.

    • This research topic has gender, age and injury-related bias that future research should address.

    How might it impact on clinical practice in the future?

    • Practitioners need to be aware that injured athletes are emotionally vulnerable, and that their emotional integrity may be questionable during rehabilitation.

    • Practitioners should encourage athletes to perceive the injury experience as an opportunity for growth and development.

    • Practitioners need to ensure injured athletes are physically, psychologically, socially, tactically and technically ready to return to sport.

    • Practitioners should not assume that physical and psychosocial recovery from injury occurs within the same timeframe.

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    View Abstract

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Twitter Follow Dale Forsdyke at @forsdyke_dale, Michelle Jones at @Michelle_inHE and Adam Gledhill at @gleds13

    • Contributors DF, AS and MJ were responsible for the conception and design of this mixed studies systematic review. DF applied the search strategy, extracted data, completed PROSPERO registration and obtained ethical approval. The peer review team (DF, AS and AG) applied the eligibility criteria at each stage, quality appraisal tool and agreed on meta-aggregated themes. DF completed the final manuscript with critical revisions made by AS, MJ and AG.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.