Pre Injury Education the key to a Smoother Rehabilitation?

Participating in sport has been shown to decrease depression, alleviate anxiety and can be used as a tool to cope with stress [1], on a professional level athletes have been shown to base a large amount of self-efficacy around their sporting achievements [2]. If an injury is to occur it is understandable that these self-efficacies will suffer and have a psychological impact on the athlete, causing interruptions to rehabilitation.

Athletes have reported a sense of disbelief and shock that the injury actually occurred and a sense of fear of the unknown as to what lies ahead in the rehabilitation process [3]. I question that if athletes were educated in the psychological process of an injury BEFORE the injury occurs, would they be better equipped to deal with the psychological aftermath of an injury?  And would a clear understanding of these processes result in a more effective rehabilitation and return to play process? In saying this, we would need to accurately determine an appropriate model of the psychological impact through injury; and this is where the problem lies. With psychological research largely based on interviews and questionnaires for data collection there is no one answer – so how can we determine the best way to educate these athletes yet keep it to a general enough theory that will hopefully encapsulate athletes on a large scale?

It is widely accepted within the sport psychology spectrum that the conceptual background of an athlete’s reaction to an injury is based loosely on the works of Kubler-Ross on death and dying[4]. After working with her terminally ill patients Kubler -Ross presented the idea that we as humans go through five stages of grief – denial, anger, bargaining, depression and acceptance/re organisation. Kubler-Ross’ grief stage theory has been applied to athletic injury, however research has failed to prove that injured athletes move in a regimented fashion through a series of stages while rehabilitating[5]. Evans and Hardy (1995)[6] suggest that in relation to sports injury grief should be viewed as “an emotional response to perceived loss, and as a process characterised by behavioural and psychological manifestations” (Evans and hardy 1995 p242).

Heil (1993)[7] has proposed a model of the affective cycle of injury that builds on Kubler-Ross’ theory and relates to sport.

The affective cycle of injury model builds on the belief that the rehabilitation process is not a one way linear process but a cycle that may repeat. This cycle consists of three key elements, distress, denial, and determined coping;


  1. Distress includes anger, bargaining with oneself (eg if I recover I promise I will be more diligent with my warm up), anxiety, depression, guilt & helplessness. Athletes regularly circle back to feelings of distress, possibly after an unsuccessful rehabilitation session or when goals are not reached in the desired timeframe.
  2. Denial is encapsulated in feelings of disbelief or in failure to accept the severity of ones’ injury – “I’ll be right to play in two weeks coach”.
  3.  Determined coping is reached when the athlete has accepted the injury and utilized their resources to plan an appropriate rehabilitation timeframe and strategy[8].

The problem of the aftermath of an injury being so extreme affects not only the athlete themselves but all those around them; teammates need to be socially aware of a necessary shift in treatment of the athlete, team doctors need to pay close attention to physical and psychological rehabilitation strategies, coaches need to decide the capacity of the athletes involvement – will they still be at training? Do they have the confidence the athlete will return to full form?  Family members will be those with the most contact and will witness the cycle of denial and distress, as well as taking on any family responsibilities the athlete is no longer able to manage either emotionally or financially.

Coaches and medical/psychological staff need to be working together to implement a model that ensures the athletes know what is psychologically possible if an injury occurs.

Athlete education in the psychological process involved in injury may not eradicate the issue of psychological distress post injury; however it may positively effect the level of distress and denial affecting athletes post injury (self-esteem, monetary, psychosocial, career ending, motivation and fear of re – injury[9]).

A possible approach in educating athletes is through exposure to mentor like figures from the sporting community. These respected members of the sporting community are able to shed light their experiences with injury as well as offering advice on managing injurys both physically and mentally. Older, respected members of the sporting community are able to anecdotally describe what they would have liked to known before they were injured in order to possibly avoid the extent of denial and distress they experienced. Taylor and Taylor’s psychological distress checklist is a tool to indicate athletes post injury mental health and could be a model utilised to develop a pre injury model of educating athletes or indicating possible emotional and mental factors if an injury was to occur[10].

By Annie Gallacher

[1] Deutsch, R. E. (1985). The psychological implications of sports related injuries. International Journal of Sport Psychology, 16(3), 232-237.

[2] Feltz, D. L., & Lirgg, C. D. (2001). Self-efficacy beliefs of athletes, teams, and coaches. Handbook of sport psychology, 2, 340-361.

[3] Tracey, J. (2003). The emotional response to the injury and rehabilitation process. Journal of Applied Sport Psychology, 15(4), 279-293.

[4] Walker, N., Thatcher, J., & Lavallee, D. (2007). Review: Psychological responses to injury in competitive sport: a critical review. The Journal of the Royal Society for the Promotion of Health, 127(4), 174-180.


[5] Brewer, B. W. (1994). Review and critique of models of psychological adjustment to athletic injury. Journal of applied sport psychology, 6(1), 87-100.

[6] Evans, L., & Hardy, L. (1995). Sport injury and grief responses: A review. Journal of Sport & Exercise Psychology.

[7] Heil, J. (1993). Psychology of sport injury. Human Kinetics Publishers.


[8] Heil, J. (1993). Psychology of sport injury. Human Kinetics Publishers.


[9] Brewer, B. W. (1993). Self‐identity and specific vulnerability to depressed mood. Journal of personality, 61(3), 343-364.


[10] Taylor, J., & Taylor, S. (1997). Psychological approaches to sports injury rehabilitation. Wolters Kluwer Health.



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