A 2018 Hess Et Al. Review of The Sport Injury and Rehabilitation Literature - From Abstraction To Application

“A Review of the Sport Injury and Rehabilitation Literature: From Abstraction to Application”
by Hess CW, Gnacinski SL, Meyer BB

The Sport Psychologist
© 2018 Human Kinetics, Inc.
Note: This article will be published in a forthcoming issue of

The Sport Psychologist. This article appears here in its accepted,
peer-reviewed form, as it was provided by the submitting author.
It has not been copy edited, proofed, or formatted by the
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Section: Professional Practice
Article Title: A Review of the Sport Injury and Rehabilitation Literature: From Abstraction to
Application
Authors: Courtney W. Hess1, Stacy L. Gnacinski2, and Barbara B. Meyer3
Affiliations: 1University of Massachusetts Boston; Department of Counseling & School

Psychology. 2Drake University; Department of Health Sciences, Des Moines, IA. 3University of
Wisconsin-Milwaukee; Department of Kinesiology - Integrative Health Care and Performance
Unit.
Running Head: Injury rehabilitation: Abstraction to application
Journal: The Sport Psychologist
Acceptance Date: November 21, 2018
©2018 Human Kinetics, Inc.
DOI: https://doi.org/10.1123/tsp.2018-0043
A Review of the Sport Injury and Rehabilitation Literature:

From Abstraction to Application
1
Courtney W. Hess, M.S., 2Stacy L. Gnacinski, Ph.D., 3Barbara B. Meyer, Ph.D.
1
University of Massachusetts Boston; Department of Counseling & School Psychology
2
Drake University; Department of Health Sciences
3
University of Wisconsin-Milwaukee; Department of Kinesiology - Integrative Health Care and
Performance Unit
Abstract
Despite advancements in sport injury rehabilitation theory (Brewer et al., 2002; Weise-Bjornstal
et al., 1998) and intervention design (Dawson et al., 2014; Rees et al., 2010), return-to-play
outcomes remain suboptimal (Rice et al., 2016). To understand the current knowledge base within
sport injury rehabilitation, authors use an existing framework (Aoyagi & Poczwardowski, 2013)
to review and outline gaps within the sport injury evidence base. Through the lens of this
framework authors highlight the dearth of literature exploring how professionals approach
rehabilitation, which may be one of several factors contributing to persistently poor rehabilitation
outcomes. To begin addressing the identified gap in practice, three established team-based
approaches from other rehabilitation domains (Karol, 2014) will be hypothetically applied to a
single sport injury case study to provide concrete examples of how team-based practice approaches
can be effectively used within the sport domain. Professional practice implications are discussed
alongside areas for future research.
Keywords: Team Approaches, Literature Review, Evidence-Based Practice, Professional Practice
Philosophy, Translational Research

As the rate of sport participation steadily increases around the globe, so too does the
frequency of sport injuries (Caine, Caine, & Maffulli, 2006). Researchers have consistently
reported high injury rates across sports (Caine et al., 2006; Maffulli, Longo, Spiezia, & Denaro,
2010; Swenson, Collins, Best, Flanigan, & Fields, 2013), staggering financial costs associated with
injury (Öztürk & Kiliç, 2013), and often deleterious outcomes for athletes who experience injury
(Rice et al., 2016). Additionally, early specialization, and the high demand for improved
performance has contributed to the subsequent rise in chronic and overuse injuries experienced by
athletes across all ages and levels of play (Ekstrand, Waldén, & Hägglund, 2016; McGuine et al.,
2017). Injury prevalence, along with the financial burden and negative psychological
consequences for athletes who experience injury, have prompted a growing demand for evidence
(i.e., empirical research, professional practice knowledge) to inform practice within sport injury
rehabilitation.
Despite consistent efforts toward improved evidence-based practice, sport injury
rehabilitation outcomes remain suboptimal at best. For example, in a study of anterior cruciate
ligament (ACL) injuries, the authors reported that nearly two-thirds of athletes had not returned to
their pre-injury level of play by their 12-month follow-up (Ardern, Webster, Taylor, & Feller,
2011). Researchers have also consistently cited high re-injury rates (30-63%) across a variety of
injury types (e.g., ACL, hamstring) and sports (de Visser, Reijman, Heijboer, & Bos, 2012;
Paterno, Rauh, Schmitt, Ford, & Hewett, 2015). Suboptimal rehabilitation outcomes also include
commonly reported psychosocial challenges and barriers associated with recovery from sport
injury (e.g., fear of re-injury or re-injury anxiety; Walker, Thatcher, & Lavallee, 2010).
Although it is not possible to fully elucidate the reasons for the abovementioned suboptimal
outcomes, researchers have pointed to a variety of institutional (e.g., models of healthcare,

insurance limitations, inconsistent professional competency requirements across professions),
theoretical (e.g., siloed training and education; Karol, 2014, ideological resistance to the
biopsychosocial model; Ardern et al., 2011), and individual (e.g., malingering; Podlog, Dimmock,
& Miller, 2011, non-adherence; Brewer, 2010) challenges. In the current paper, the authors explore
another challenge that may contribute to poor outcomes - a potential shortcoming in current
practices of sport injury rehabilitation that seems to permeate many of the aforementioned barriers
to improved outcomes. That is, despite novel theoretical conceptualizations of sport injury and
rehabilitation, alongside a rapidly evolving body of intervention literature available to
rehabilitation professionals, gaps in the translation of that evidence to practice are evident. These
gaps, along with evidence from general healthcare which has directly linked fragmented healthcare
practices and breakdowns in team functioning to suboptimal patient outcomes (Rosen et al., 2018;
The Joint Commission, 2015) support an examination of professional practice approaches within
sport.
To identify gaps in the translation of evidence to practice, the philosophy underpinning
what is currently known about injury case conceptualization and rehabilitation intervention must
first be considered. Across domains (e.g., counseling, psychotherapy, sport psychology),
substantial emphasis is placed on the direct link between professional philosophy and subsequent
intervention selection, implementation, and evaluation (Poczwardowski, Sherman, & Ravizza,
2004). Such professional philosophies are thought to be informed by theoretical paradigms,
practice approaches, and intervention techniques within boundaries of competency
(Poczwardowski et al., 2004). Based on prior work within the counseling domain (Prochaska &
Norcross, 2011), Aoyagi and Poczwardowski (2013) recently proposed the application of a
classification system to categorize models of sport psychology practice and delivery according to
their level of philosophical abstraction. To illuminate the gaps in the translation of evidence to
practice, a similar process is considered in the current paper, whereby the theoretical paradigms,
practice approaches, and intervention techniques surrounding sport injury rehabilitation are
categorized into three different levels of abstraction - high, medium, and low.
The high level of abstraction includes the overarching models and paradigms that guide
conceptualization of a phenomenon. For sport injury rehabilitation, this encompasses the
biomedical and biopsychosocial paradigms, which provide a comprehensive framework for
thinking about the injury experience for athletes. The medium level of abstraction involves
frameworks and approaches to guide practice and delivery. In sport injury rehabilitation, the
medium level of abstraction includes the approaches used by professionals in practice (i.e., lone
practitioner, multidisciplinary, interdisciplinary, transdisciplinary), thereby representing a shift
from thinking about sport injury to doing the work of rehabilitation. The low level of abstraction
is characterized by the individual interventions and techniques that practitioners implement when
working with athletes. In sport injury rehabilitation, this includes interventions such as breathing
techniques for reducing pain in recovering athletes, thus representing the shift from how
rehabilitation practice is done to what specific interventions need be employed for a given case.
All three levels of abstraction are necessary for case conceptualization to optimize sport
injury rehabilitation practice. In the ideal scenario (see Figure 1), each level of abstraction should
inform the next, creating a linear progression of knowledge from the broadest, most abstract
conceptualization of sport injury to the most nuanced explanation of evidence-based interventions.
For example, adoption of the biomedical paradigm historically resulted in a lone-physician
approach whereby a single practitioner was responsible for all rehabilitation needs, and
interventions were largely focused within a single discipline, most predominantly the
physiological domain. By contrast, the more current biopsychosocial paradigm describes injury
as multifaceted, which necessitates application of a team-based approach to sport injury
rehabilitation, and interventions that involve a variety of disciplines. Without evidence at the
medium level of abstraction, scholars are unable to provide guidance on team-based approaches,
thereby contributing to a dearth of team-based approaches employed in practice (Fiscella &
McDaniel, 2018). Therefore, practitioners adopting a biopsychosocial paradigm are more likely
to bypass the medium level of abstraction during case conceptualization and move directly to
intervention selection and delivery. In keeping with the biopsychosocial paradigm, solo
practitioners may then attempt to deliver interventions across disciplines without adequate
training, thereby increasing the potential for inadequate interventions and harm to the client.
To date, most of the scholarly work surrounding sport injury rehabilitation reflects a
concentrated effort towards accumulating knowledge at the high (Brewer, Andersen, & Van
Raalte, 2002; Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998) and low levels of abstraction
(Dawson, Hamson-Utley, Hansen, & Oplin, 2014; Mitchell, Evans, Rees, & Hardy, 2013; Rees,
Mitchell, Evans, & Hardy, 2010; Yu & Hsu, 2013). However, there is an absence of knowledge
at the medium level of abstraction which would inform best practices for implementing team-based
approaches in sport injury rehabilitation. As such, it is perceivable that the absence of literature at
the medium level of abstraction is part of the multifaceted and systematic challenges contributing
to suboptimal rehabilitation outcomes.
To facilitate improved rehabilitation outcomes, the purpose of the current paper is to begin
to bridge the gap between the way in which injury and rehabilitation are conceptualized in theory,
and the way in which they are approached in practice. To do this, the authors will provide an
overview of current rehabilitation literature, and within that literature highlight concepts that are
important to the medium level of abstraction. Additionally, the authors will describe three
emergent practice approaches in sport injury rehabilitation, which mirror approaches that have
been used in the general healthcare domain for more than 30 years (Karol, 2014; Körner, 2010;
Melvin, 1980). Taken together, the information reviewed, and concepts introduced will be used
to provide directions for future lines of inquiry as well as implications for practitioners.
Theoretical Paradigms for Understanding Sport Injury
Biomedical Model
Throughout westernized medicine, the biomedical model has underpinned the
conceptualization of injury and sickness over the preceding century. Within this paradigm, injury
and sickness are defined as biological defects, and the aim of treatment is to eliminate or mitigate
identified defects (Engel, 1977). Given the unidimensional conceptualization of sickness within
this paradigm, concerns outside of biological defects, such as mental health, are not considered
(Engel, 1977; Johnson, 2012). During the time in which the biomedical model emerged, rates of
mortality were predominantly linked to biological disease and so conceptualizing injury and
sickness through a unidimensional paradigm was largely supported by improved patient outcomes
(Engel, 1977).
In applying the biomedical model to sport, injury is conceptualized as any physical defect
present in an athlete, and rehabilitation efforts are aimed at improving the physiological
functioning of the athlete. The influence of this paradigm in sport injury rehabilitation is evident
in return-to-sport guidelines, whereby an athlete’s readiness to play is predominantly assessed by
biological markers alone (Creighton, Shrier, Shultz, Meeuwisse, & Matheson, 2010; Herring,
Kibler, & Putukian, 2012). Despite the obvious importance of restoring athletes’ physiological
functioning, the biomedical paradigm falls short in adequately guiding practitioners toward
successful rehabilitation conceptualization, and intervention, as evidenced by poor return
outcomes. In turn, questions surrounding adherence to rehabilitation protocols, failure to return-
to-sport despite physiological healing, and psychological disturbance arising amidst injury
(Brewer, 1998), highlighted the need to more comprehensively investigate the injury rehabilitation
process and factors influencing rehabilitation outcomes. In light of identified limitations of using
the biomedical model to explain the injury experience, use of the paradigm to understand the
process of sport injury rehabilitation has greatly diminished beyond the late 1970s.
Biopsychosocial Model
Seminal research published by George Engel (1977) prompted a shift in the
conceptualization of health, as he called into question the reductionist nature of the biomedical
model and the disregard for non-physical ailments presented by patients. Engel’s work specifically
highlighted the inconsistency between the biomedical model and the 1948 World Health
Organization’s definition of wellness, which describes health and wellness as a “complete state of
physical, mental, and social well-being, and not merely the absence of disease” (Official Records
of the World Health Organization, 1948, p. 100). The shift toward a more comprehensive
definition of health and wellness prompted the emergence of several biopsychosocial models,
which acknowledge the physiological, psychological, and sociological factors that contribute to
the explanation of health and sickness (Engel, 1977). Within sport injury and rehabilitation, the
path to establishing biopsychosocial models of injury and rehabilitation began with research aimed
at understanding both the psychosocial antecedents (i.e., stress-injury model, Andersen &
Williams, 1988) and consequences of injury (i.e., cognitive appraisal model, Wiese & Weiss,
1987).
The integrated model of response to sport injury. Expanding the work of Wiese and
Weiss (1987), a theoretical paradigm emerged in the injury and rehabilitation literature which more
closely represented a comprehensive biopsychosocial paradigm (Wiese-Bjornstal et al., 1998).
Similar to previously established research (Wiese & Weiss, 1987), authors of the integrated model
of response to sport injury (Wiese-Bjornstal et al., 1998) affirm that an athlete’s cognitive appraisal
will influence their emotional response which will affect their behavioral response through
rehabilitation. The authors expand on the established model whereby they propose how the initial
athlete appraisal is impacted by the athlete’s own unique personal (e.g., age, gender, personality)
and social (e.g., accessibility, team support) factors. Additionally, the authors suggest that the
triadic relationship between thoughts, feelings, and behaviors—termed the dynamic core—can
operate bi-directionally such that behaviors can influence emotions and therefore subsequent
athlete appraisals throughout the rehabilitation process. The authors describe that the valence of
the dynamic core can help to explain an athlete’s rehabilitation process and observed outcomes.
For example, positive cognitive appraisals will improve emotional responses which will then elicit
more positive behaviors related to injury rehabilitation (e.g., compliance to rehabilitation
protocols) while negative cognitive appraisals will elicit poor coping responses across the
rehabilitation process (e.g., rehabilitation avoidance, substance abuse). Evidence to date has
widely supported the use of this model for improving the overall conceptualization of sport injury
rehabilitation (Carson & Polman, 2008; Langford, Webster, & Feller, 2008), as well as the use of
various model components in isolation for informing interventions aimed at improved
rehabilitation outcomes and experiences (e.g., social support; Mitchell et al., 2013; Rees et al.,
2010; Yu & Hsu, 2013, imagery; Evans, Hare, & Mullen, 2006). Notwithstanding the evidence in
support of this theoretical paradigm, the lack of explanation surrounding how the personal and
situational factors interact to influence cognitive appraisal, as well as the absence of the physical
aspects of recovery in the model, have been identified as model weaknesses (Walker, Thatcher, &
Lavallee, 2007).
The biopsychosocial model of sport injury rehabilitation. The biopsychosocial model
of sport injury rehabilitation (Brewer et al., 2002) expands upon Wiese-Bjornstal and colleagues’
paradigm through the inclusion of physiological influences of injury rehabilitation. In addition,
Brewer et al. (2002) accounted for possible interactions between factors, and propose that
sociodemographic factors in combination with characteristics of the injury will directly influence
the biological, psychological, and socio-contextual factors for a given athlete. Biological,
psychological, and socio-contextual factors may also interact to influence intermediate

biopsychosocial outcomes, which ultimately facilitate or debilitate rehabilitation outcomes.
Additionally, Brewer et al. suggest a direct link between psychological factors and rehabilitation
outcomes, thereby highlighting the impact of psychological recovery for athletes (2002). Given
the theoretical consistencies between paradigms, much of the evidence supporting the use of the
integrated model of response to sport injury mutually supports the biopsychosocial model of sport
injury rehabilitation and vice versa (Dawson et al., 2014; Meyer & Ebersole, 2007; Podlog &
Eklund, 2009; Rees et al., 2010; Wadey et al., 2014). Identified shortcomings of the
biopsychosocial model include minimal discussion of how the identified factors influence
rehabilitation outcomes, and to that end, the limited scope of defined rehabilitation outcomes
(Brewer, 2010).
Summary
The literature on injury and rehabilitation reviewed above represents the time spent over
the preceding decades generating knowledge at the highest level of abstraction (Aoyagi &
Poczwardowski, 2013), and sets the foundation for how practitioners currently think about sport
injury, how desired rehabilitation outcomes are defined, and how we form expectations
surrounding the rehabilitation experience for athletes. Although the models described above have
been affirmed within sport literature to offer a valid framework for understanding sport injury and
rehabilitation, their purpose is to provide just that, a theoretical framework to conceptualize sport
injury and rehabilitation, and thus are not intended to directly inform interventions. Using the
models in that way highlights a weakness in the knowledge base of sport injury rehabilitation,
whereby high level abstraction models are utilized to directly inform interventions (i.e., low level)
rather than to inform the more proximal tier of abstraction - professional practice approaches to
sport injury rehabilitation (i.e., medium level). Without evidence at the medium level of
abstraction to inform professional practice within sport injury rehabilitation, it is not surprising
that a disparate body of literature has emerged out of professional practice describing various
approaches to rehabilitation.
Professional Practice Approaches in Sport Injury Rehabilitation
In sport, practitioners across competitive levels have provided anecdotal or professional
practice evidence for three different team-based approaches to sport injury rehabilitation (Clement
& Arvinen-Barrow, 2013; Dijkstra, Pollock, Chakraverty, & Alonso, 2014; Meyer, Merkur,
Massey, & Ebersole, 2014). Further consideration of these approaches is warranted given their
potential to help fill the current knowledge gap at the medium level of abstraction. To facilitate
increased generalizability of the identified team-based approaches, evidence across a variety of
sport domains, along with consistent operational definitions for each approach, is necessary.
Therefore, informed by practices within the general healthcare domain, and the operational
definitions provided therein, the authors will compare the descriptions of the sport rehabilitation
approaches borne of professional practice with those approaches established and supported by
empirical and professional practice evidence in other healthcare domains. As the authors examine
practice approaches from both the general healthcare domain as well as the sport domain, person
and athlete are used interchangeably across the approach descriptions (e.g., person-centered,
athlete-centered).
Lone Physician
The lone physician approach, in alignment with the biomedical paradigm, has dominated
both general medicine and sport-specific medicine over the past century. The lone physician
practice approach places responsibility for care on a single physician who thereby determines all
medical processes and choices for the patient (Karol, 2014). The patient voice is absent within
this approach, as the physician’s focus is healing the identified biological defect and not the patient
as a whole (Melvin, 1980). Although in theory, the lone physician approach to injury rehabilitation
is considered inferior to approaches aligned with the biopsychosocial model, it is still commonly
utilized in practice as evidenced by continual reports of return-to-play decisions based unitarily in
physical measures of healing (Creighton et al., 2010; Herring et al., 2012). Additionally, the
majority of return-to-play guidelines are still created solely by physiologically-focused
professionals (van der Horst, van de Hoef, Reurink, Huisstede, & Backz, 2016), and return-to-play
decisions are often made by a lone professional (Creighton et al., 2010).
Multidisciplinary Approach
In response to the paradigm shift toward biopsychosocial models of health, the way in
which patient care was conceptualized in practice shifted toward a team-based approach. The first
team-based approach established is termed the multidisciplinary approach and is defined by the
presence of multiple professionals from diverse disciplines simultaneously working on outcomes
for a single patient. Within this approach, each professional is working toward individual,
discipline-specific goals with little to no consistent communication between team members (Karol,
2014). Empirical findings from the healthcare domain have long supported the efficacy of
multidisciplinary treatment teams, with evidence pointing to improved patient outcomes (Khan,
Pallant, Zhang, & Turner-Stokes, 2010; Patti et al., 2003). Researchers have also established the
efficacy of multidisciplinary approaches to rehabilitation services across a variety of populations
and medical conditions (Griffiths et al., 2000; Khan et al., 2010).
In sport, an approach published by Clement and Arvinen-Barrow (2013) is the most
consistent with the multidisciplinary approach described previously in other rehabilitation

contexts. The authors describe team-based work such that an athlete is treated by a network of
diverse helping professionals (e.g., athletic trainers, sport psychologists, physiotherapists,
orthopedic surgeons, nutritionists) who will work toward improving a range of factors that have
been established as important to rehabilitation outcomes (e.g., psychological, physiological). The
authors suggest that these professionals may or may not collaborate across the course of the
rehabilitation process and, depending on the injury, certain professionals may play a more or less
dominant role in treatment. Clement and Arvinen-Barrow outlined the importance of
communication between professionals as helpful for improving treatment, particularly the need for
well established and coordinated referral pathways. The primary care team is described as a single
physician and athletic trainer who lead the rehabilitation process and may have communication
with secondary rehabilitation team members for logistical reasons. Additionally, the athlete is
visually depicted at the center of the rehabilitation team, highlighting the importance of team
members working for the benefit of the athlete. Although professionals are working for the athlete,
the proposed approach is most commensurate with low-levels of person-centered care, as athletes
are not integrated into the rehabilitation team, which is a defining feature of the multidisciplinary
approach (Karol, 2014). More recent empirical findings by these authors (Arvinen-Barorow &
Clement, 2015; Arvinen-Barrow & Clement, 2017) revealed an emerging importance of athlete-
centered work from the perspective of practitioners. It is therefore possible that a future iteration
of this approach may warrant reclassification based on defintions provided within this manuscript.
It is feasible that in current form Clement and Arvinen-Barrow’s multidisciplinary
approach to rehabilitation would be beneficial for improving outcomes among injured athletes.
Based on outcomes from the healthcare literature, we may anticipate improvements in an athlete’s
social functioning and mental health status during and after rehabilitation (Van den Berg et al.,
2005). Additionally, the applicability of the multidisciplinary approach across sport settings and
the potential to serve a large number of injured athletes simultaneously are notable identified
benefits (Griffiths et al., 2000; Khan et al., 2010). However, evidence of the efficacy of the
multidisciplinary approach within the sport domain is lacking.
Interdisciplinary Approach
Following the multidisciplinary approach, the general healthcare domain continued to push
towards increased collaboration among team members, resulting in the interdisciplinary approach.
The interdisciplinary approach is similar to the multidisciplinary approach in that it calls for
multiple professionals from diverse domains to be focused on discipline-specific work. However,
the interdisciplinary approach goes beyond the call for coordinated rehabilitation efforts and
established referral networks, imploring rehabilitation team members to engage in meaningful
communication and authentic collaboration surrounding the needs, goals, and progress of a single
patient (Karol, 2014). Melvin (1980) described the interdisciplinary approach to patient care as
“synergistic, producing more than each individually and separately could accomplish” (p. 380).
Similar to multidisciplinary approaches in healthcare, empirical findings support the efficacy of
an interdisciplinary approach across rehabilitation settings, and in some settings researchers have
observed improved outcomes when compared to a multidisciplinary approach (Körner, 2010;
Richardson et al., 2014; Semlyen, Summers, & Barnes, 1998). To that end, previous findings have
also indicated that healthcare professionals prefer to work within an interdisciplinary team over a
multidisciplinary team, for reasons such as improved perceptions of collaboration, work climate,
group cohesion, and work satisfaction (Farrell, Schmitt, & Heinemann, 2001; Sinclair, Longard,
& Mohabeer, 2009). In addition to the perceived improvements in working climate for healthcare
professionals, scholars have also suggested that interdisciplinary approaches may yield superior
rehabilitation outcomes when compared to a multidisciplinary approach. For example, research
findings from the healthcare domain suggested that an interdisciplinary approach was superior in
improving symptoms of depression among youth (Richardson et al., 2014) and increased
functional independence following a traumatic brain injury among adults (Körner, 2010).
Within the sport domain, sports medicine practitioners from the United Kingdom reported
their practice approach for working with athletes during the 2012 Summer Olympic Games
(Dijkstra et al., 2014). The authors termed the approach the integrated performance health
management and coaching model, which emphasizes communication and collaboration between
two, often disparate, domains—performance coaching and performance health management. The
authors suggest that all team members should consider an athlete’s wellness on a continuum rather
than a dichotomous state (i.e., injured or healthy). Therefore, in scenarios which present
suboptimal physiological data around recovery, the coaching health management staff may
collaboratively evaluate the risks of competing in light of the high-stakes context of the sporting
event (i.e., Olympics). In all situations, the need for data from multiple disciplines as well as
communication and collaboration between professionals in those disciplines is emphasized. In
calling for increased cooperation between these two domains, the authors highlight a gap in sport
practice to integrate the preference of the athlete and their support staff. To begin to bridge the
identified gap, Dijkstra and colleagues acknowledge that inclusion of athlete and coach preferences
into some medical decision-making processes may be warranted, particularly when identifying
goals for treatment and when making return-to-play decisions. Despite the acknowledgement of
incorporating athlete and coach preferences in the delivery of services, they do not describe the
athlete as integrated within the ongoing, day-to-day decision-making processes of rehabilitation.
With a high emphasis on collaboration and a low emphasis on person-centered care, this approach
is most consistent with an interdisciplinary approach (Karol, 2014).
The integrated performance health management and coaching model was used at the 2012
Olympic Summer Games and, given the call for collaboration between practitioners in distinct
disciplines along with limited inclusion of the athlete voice in rehabilitation decision-making, is
most closely aligned with the interdisciplinary approach within general healthcare (Karol, 2014).
In light of previously established benefits of the interdisciplinary approach, it is reasonable to
believe that improved feelings of autonomy for the athlete, reduced burnout for the sports medicine
professionals, as well as improved speed and quality of injury rehabilitation would be observed in
the sport domain (Körner, 2010; Richardson et al., 2014; Sinclair et al., 2009). However, evidence
within sport that can be replicated and generalized is necessary to further support the efficacy and
effectiveness of the approach.

Transdisciplinary Approach
The transdisciplinary approach retains the call for communication and collaboration among
team members, yet rather than dividing a patient’s needs into distinct disciplines, advocates for
patient-centered, problem-focused work. In this approach the patient’s needs are collaboratively
defined by all members of the rehabilitation team, including the patient, and all members of the
team then contribute their unique knowledge to the collaboratively defined hierarchy of needs
(Karol, 2014). Additionally, practitioners go beyond just considering the requests of the patient to
understanding the necessity of the patient as the center of the rehabilitation team (i.e., person-
centered approach). The person-centered care demands role release and optimal integration
whereby the involvement of the entire team is necessary for all treatment decisions. Therefore,
even when a problem may seemingly fit within a specific domain of expertise, Karol (2014)
suggests that truly integrated care happens when the knowledge of each professional is valued and
used to make treatment decisions. Beyond theoretical support for the model, recent evidence
within the general healthcare domain supports the efficacy of the transdisciplinary approach for
the management of challenging and complex health problems such as chronic pain, and dementia
(Galvin, Valois, & Zweig, 2014; Gordon et al., 2014).
In sport, the Meyer athlete performance management model (MAPM) most closely aligns
with the transdisciplinary approach (Meyer et al., 2014). The MAPM emerged out of decades of
professional practice from practitioners in diverse domains within elite sport as a general
performance model, and in recent years has been evaluated explicitly for the purposes of sport
injury rehabilitation (Hess, unpublished thesis 2015). Within the MAPM model, the authors
propose that a fully integrated team must surround an athlete to facilitate optimal sport
performance. The authors of the MAPM suggest that professionals from the mental (e.g., sport
psychologist), physical (e.g., athletic trainer, doctor, physiotherapist), technical (e.g., skills coach,
position coach), and senior management operations (e.g., National Governing Organization,
rehabilitation manager) need to work collaboratively, engaging in ongoing communication with
one another to facilitate optimal team performance, and rehabilitation outcomes. In addition to
positioning the athlete at the center of the team, the authors suggest that all professionals around
the athlete collaborate with the athlete across the entire rehabilitation process to promote optimal
outcomes, thereby representing a high level of person-centered care consistent with a
transdisciplinary approach. In providing examples of the work in practice, the authors describe
problems that arose across the course of an Olympic quadrennial, and how in response, all
members of the team were required to shift to meet those needs despite their respective
professional domains. The emphasis on athlete-centered care, coupled with the call for
collaborative and problem-focused work rather than discipline-specific work, prompts the
identification of the model as a transdisciplinary approach. While anecdotal evidence for the utility
of the MAPM approach in elite sport has been described, given findings in the general healthcare
domain it is foreseeable that this team approach would elicit increased empowerment (Galvin et
al., 2014), engagement, and motivation (Smithson & Kennedy, 2012) for the athlete as well as
decreased burnout for sports medicine practitioners.
Summary
In the literature reviewed above, clarity is offered surrounding operational definitions for
professional practice approaches that have emerged within the sport domain. While empirical
support exists for the use of the reviewed team-based approaches in general healthcare, little
empirical evidence exists to establish the efficacy of team-based approaches in improving
rehabilitation outcomes for injured athletes. To this end, persistently poor rehabilitation outcomes,
amid quality empirical and professional practice evidence at the high and low levels of abstraction,
prompt the need to fill the gap in evidence at the medium level of abstraction. Therefore, to further
illustrate the nuances between multi-, inter-, and transdisciplinary approaches to rehabilitation, the
authors will provide explicit practice-based examples of each approach within the context of a
previously published injury case (Meyer & Ebersole, 2007). In so doing, we hope to highlight
important factors that should be considered in future empirical research methodology as well as
intervention design within professional practice.
Team-Based Approaches to Rehabilitation Practice in the Context of Sport
A visual schematic (Figure 2) was constructed to convey differences between multi-, inter-
, and transdisciplinary rehabilitation team structures in sport environments. There are several
details germane to the interpretation of Figure 2. First, each sphere represents a broad domain of
professionals (i.e., medical, high performance director, athlete, physical, technical, psychological)
that have been suggested to be important in the context of elite sport (Meyer et al., 2014). Second,
the size of each sphere represents relative domain importance regarding decision-making authority
(i.e., rehabilitation protocols, return-to-sport, return-to-competition) throughout the rehabilitation
process. Third, the proximity of each sphere to the athlete represents the relative importance of
that domain within the rehabilitation process. Fourth, the arrows in Figure 2 represent the typical
flow of communication across and between members of the rehabilitation team, including the
athlete. Lastly, the figure represents proposed team-based approaches to sport injury rehabilitation
that are informed by current descriptions within the general healthcare domain (Karol, 2014), and
do not necessarily mirror perfectly the aforementioned approaches reported in sport.
Based on the last author’s decades of professional experience working with athletes across
levels of competition, professionals in the medical (MED) domain typically include orthopedic
surgeons, general or family medicine practitioners, and/or other licensed medical professionals.
In the physical (PHYS) domain, professionals often include physiotherapists or physical therapists,
athletic trainers, and strength and conditioning coaches. Professionals in the technical (TECH)
domain generally include the coaching staff and equipment personnel. In the psychological
(PSYCH) domain, professionals might include mental performance consultants, sport
psychologists, and/or licensed mental health professionals. Finally, within the organizational
domain (ORG), the high performance director typically holds most prominent influence, yet others
in the organization (e.g., board of directors, front office personnel) are also included within this
sphere.
In order to highlight the distinct nuances of each team-based approach, the authors will
explain each of the three approaches in Figure 2 vis-à-vis the same injury case study (Meyer &
Ebersole, 2007). As such, and to hypothetically describe each of the three team-based approaches
within elite sport environments, the events and details of the athlete’s rehabilitation process have
been modified. Before proceeding to applications of team-based approaches to the case, and to
provide the reader with context required for case conceptualization, information about the athlete’s
sport, career accolades, injury occurrence, and rehabilitation team are presented below.
Case Example
Sport. Aerial skiing is a form of freestyle skiing in which the athlete skis down a steep in-
run and launches off a snow kicker to propel 10-20 meters into the air (Wylie, 1999). Once in the
air, the athlete performs acrobatic twists and somersaults, and then finishes by landing on a 25-
meter hill (Wylie, 1999). To reduce injury risk, and for logistical reasons (i.e., snow demands),
technical practice sessions typically include a combination of jump-training modalities: (a)
bungee-assisted trampoline, (b) water ramping into aerated pools, and (c) aerials sites on snow.
Aerial skiing athletes are at high risk of injury, with recent reports indicating injury rates as high
as 55 per 100 athletes across the previous 10 World Cup seasons (Flørenes, Heir, Nordsletten, &
Bahr, 2010; Haaland, Steenstrup, Bere, Bahr, & Nordsletten, 2016; Meyer & Ebersole, 2007).
Athlete. At the time of injury, the female, 29-year old veteran athlete was in the 3rd year
of a standard Olympic quadrennial, preparing for her second Olympic Winter Games (OWG). The
athlete was highly decorated (e.g., one Olympic gold medal, 19 World Cup podiums, two World
Cup Grand Prix titles), and thus, she and her governing sport organization held mutually high
hopes for medal potential in the upcoming OWG. The athlete had sustained injuries across her
career and was accustomed to the injury and rehabilitation process.
Injury occurrence, rehabilitation plan, and professionals involved. Nineteen weeks

prior to the OWG, and while practicing a quadruple-twisting double flip during a water ramp
training session, excessive rotation and speed coming into the aerated landing pool led to the
athlete rupturing her ACL. Given that the OWG were fast approaching, a cadaver graft was
employed for ACL repair and the athlete’s accelerated ACL rehabilitation protocol was initiated
immediately following injury. The way in which the chief medical officer (CMO), who is charged
with the oversight of the athlete’s rehabilitation plan, thinks about the injury rehabilitation process
(i.e., high level of abstraction) will directly inform the structure of the rehabilitation team (i.e.,
medium level of abstraction). The chief medical officer (CMO) could have conceptualized the
athlete’s ACL repair as a unidimensional physical experience whereby only a lone practitioner
would have been employed to physically rehabilitate the athlete (e.g., physiotherapist, strength and
conditioning coach). Consistent with the biopsychosocial model of injury, however, the CMO
instead conceptualized the athlete’s rehabilitation process as a psychological, physical,
sociological, and technical process. As such, the CMO opted to facilitate a team-based approach
to manage the rehabilitation process and organized a meeting to identify the needs of the athlete
and therefore the necessary allied health professionals to be involved. In the end, the identified
team included the CMO, head coach (TECH), sport psychology consultant (PSYCH),
physiotherapist (PHYS), and strength and conditioning coach (PHYS). Given the preceding
logistics of the case and informed by existing evidence within general healthcare (Karol, 2014),
the authors will next describe the hypothetical injury case through the three distinct team-based
approaches (Figure 2).
Hypothetical scenario #1: Multidisciplinary approach to rehabilitation. The
multidisciplinary approach is characterized by the presence of multiple professionals from diverse
disciplines working toward individual, discipline-specific goals with little to no consistent

interaction among team members (Karol, 2014; Melvin, 1980). In the current case, the small
primary rehabilitation team consists of the CMO and physiotherapist, with the physiotherapist
responsible for the majority of care across all phases of rehabilitation (Arvinen-Barrow & Clement,
2017). In the post-operative phase of rehabilitation, when the goals are to manage pain and
swelling, the athlete saw the physiotherapist daily to complete interventions such as but not limited
to icing, elevation of the limb, and passive ROM. Concurrently, the athlete met with the sport
psychology consultant several times each week, during which interventions such as relaxation and
imagery were employed. The CMO, CEO, head coach, and the strength and conditioning coach
would not be involved in the athlete’s care during this phase. Minimal communication occurred
between rehabilitation team members, and the athlete was responsible for adhering to interventions
across domains. Furthermore, the athlete played a minimal role in care-related decision-making
from the onset of injury through the return-to-competition phase. Rather, return-to-sport decisions
were made primarily by the CMO. The CMO may have chosen to reflect on the case notes and
opinions of all rehabilitation professionals yet worked primarily if not exclusively with
professionals in the physical domain (e.g., physiotherapist) to make such decisions.
Anticipated outcome. In line with the goals described above, the athlete’s pain and swelling
were successfully managed to allow for progression to the next phase of rehabilitation. Yet due to
the siloed nature of the rehabilitation professionals, the athlete’s anxiety related to her transition
back to strength training went unnoticed and unaddressed. Furthermore, the athlete’s desire to
return to competition, in combination with ongoing positive reinforcement from her rehabilitation
team about her physical markers of recovery, resulted in the athlete refraining from expressing her
anxiety and attempting to manage her feelings independently. As such, she engaged in negative
coping behaviors while away from sport and was intentionally conservative during her
physiotherapy exercises in the next phase of rehabilitation.
Hypothetical scenario #2: Interdisciplinary approach to rehabilitation. The
interdisciplinary approach to sport injury rehabilitation is characterized by increased
interdependence and collaboration among team members, surrounding the needs, goals, and
progress of a single patient (Karol, 2014). As outlined by Dijkstra and colleagues (2014), emphasis
is placed on collaboration between often disparate domains of professional practice. Within the
current case, collaboration between disparate domains of practice meant that there was
interprofessional cooperation between the PHYS, TECH, PSYCH, and ORG domains.
Additionally, Dijkstra et al. (2014) encouraged consideration of the athlete’s preferences when
designing rehabilitation plans and implementing collaborative care for the athlete. In the current
case, the athlete’s preference was to return-to-sport at all costs to long-term health, as the
opportunity to compete in the upcoming OWG far outweighed any concerns she had about chronic
arthritis, possible knee replacements, and/or physical disability after retirement. Thus, with the
opinion of those in the MED and PHYS domain, and in collaboration with those in the PSYCH
domain to help prepare the athlete for the rehabilitation process, plans for a more aggressive and
accelerated approach to ACL rehabilitation were employed. Following initial collaboration in goal
setting and rehabilitation planning (i.e., return athlete to competition for OWG in 19 weeks),
professionals in the current case established discipline-specific goals and interventions to facilitate
achievement of the superordinate goal defined above. However, as a result of increased
interprofessional collaboration, professionals acknowledged that clinical issues fell within
multiple professionals’ scopes of practice and therefore engaged in increased communication
surrounding intervention planning and implementation.
The coordination of care during the strength training phase of rehabilitation can be used as
an example to demonstrate the increased collaboration among professionals. During the last two
weeks of her muscular strength program, the strength and conditioning coach noted two
concerning observations of the athlete during sessions: (a) poor biomechanics during single leg
jump landings off a box, and (b) excessive negative self-talk statements (i.e., “I can’t, I just don’t
think my body is ready”). As the observed clinical issues had overlap with other colleagues’ areas
of expertise, the strength and conditioning coach discussed her observations with the head coach
and sport psychology consultant. Following this conversation, the coach adjusted the plan for the
next day's trampoline drills, such that the athlete would not progress to twisting maneuvers during
single flips until single leg box landings during strength workouts had improved. Concurrently,
the sport psychology consultant designed and employed a self-talk intervention aimed at
improving the athlete’s confidence in her ability to manage challenges through her rehabilitation.
Professionals in this example remained within their own domain of competence but engaged in
communication across domains where additional support was necessary. Additionally, within this
interdisciplinary approach, athlete involvement occurs during the initial planning and goal-setting
stages but, as exemplified above, may subside throughout the rehabilitation process.
Anticipated outcome. As an outcome of the interdisciplinary approach, the athlete
experienced improved confidence in her physical recovery and the ability of her knee to withstand
increased load. Therefore, although the athlete was initially slowed in her training plan, the allotted
time provided the athlete the opportunity to develop confidence in her body’s physical ability.
Going forward, the increased confidence helped to mitigate potential re-injury due to altered
movement patterns (e.g., hesitating during a rotation), as the athlete executed her skills with
confidence.
Hypothetical scenario #3: Transdisciplinary approach to rehabilitation. Akin to

interdisciplinary work, the transdisciplinary approach to sport rehabilitation is characterized by
increased interdependence and collaboration among team members, yet the transdisciplinary
approach places novel emphasis on delivering person-centered care (Karol, 2014). Rather than
rehabilitation goals and problems being assigned to a single discipline and professional on the
team, all problems and decisions are deemed within the scope of all team members. As such, and
consistent with the description by Meyer and colleagues (2014), the athlete-centered nature of the
MAPM allows for professional roles to shift with respect to the athlete’s immediate and future
needs. In the current case example, the athlete had a highly developed rapport with both her head
coach and sport psychology consultant, thus warranting continued proximal involvement of those
two parties in the rehabilitation process. Because in a transdisciplinary structure the CMO and
CEO are involved infrequently in the day-to-day rehabilitation process with the athlete, these two
domains are ancillary circulating entities around the rehabilitation team. Thus, the rehabilitation
team operates autonomously under the medical guidance and organizational parameters in place.
As described by Karol (2014), a hallmark of transdisciplinary rehabilitation teams is the
shift to thinking about client needs as singular clinical priorities that require the consideration of
all disciplines, rather than multiple needs that are addressed by discrete disciplines. The
application of transdisciplinary care during the return-to-sport phase of rehabilitation can be used
as an example to demonstrate this phenomenon. During the final rehabilitation phase, the priority
is to facilitate the athlete’s return to skiing and jumping. As such, and because the athlete shared
close working relationships with the head coach and sport psychology consultant, these two
individuals worked together on developing imagery scripts and video analysis exercises to enhance
the neural activation patterns necessary for real-life skiing and jumping. During the transition
from the strength training phase of rehabilitation (i.e., heavy reliance on the physical domain of
rehabilitation) to the return-to-sport phase, the rehabilitation team proactively anticipated the
athlete’s emotional sensitivity to transitions in care givers and her daily schedule. As such, the
head coach attended all physiotherapy and strength and conditioning sessions with the athlete. In
so doing, the athlete’s emotional and interpersonal needs were met and her confidence in the care
transition was concurrently addressed. Furthermore, all members of the rehabilitation team
participated with the athlete during video analysis sessions, despite that activity typically falling
under the purview of the technical domain. Following the video analysis session, and with expert
guidance from the sport psychology consultant, all professionals designed one integrated mental
imagery script designed to improve decision-making speed during a complicated shift in focus
during takeoff (i.e., technique) to landing (i.e., vision, biomechanics). As an example of athlete-
centered flexibility in rehabilitation, a unique modification was made to the integrated imagery
script whereby the head coach recorded the script as the athlete most appreciated hearing the voice
of the head coach when learning and practicing technical details of a jump. As demonstrated by
this example, the overlap between disciplines in a transdisciplinary team structure requires a
relatively constant and consistent flow of communication between professionals to optimize
rehabilitation outcomes (Karol, 2014; Körner, 2010; Meyer et al., 2014).
Anticipated outcome. The outcome of the transdisciplinary team approach was a confident
athlete who was prepared socially, physically, and mentally to return to competition. The athlete
felt both supported by her rehabilitation team and had developed a sense of agency over her
rehabilitation process, thereby facilitating comfort in reporting any concerns that needed ongoing
attention. Additionally, as the workload of preparing the athlete for return to sport was distributed
across all team members, members of the PMT also felt supported and energized despite a
challenging rehabilitation process. The athlete returned to sport feeling mentally and physically
stronger than she was even prior to the injury.
Summary
The hypothetical examples above demonstrate how each team-based rehabilitation
approach might be applied in elite sport environments. Main distinguishing features between
approaches include: (a) selection/inclusion of professionals from various domains, (b) relative
decision-making authority during rehabilitation, (c) proximity and relative contribution of the
professional domain to the athlete’s rehabilitation, and (d) the amount and consistency of flow of
communication between professionals and the athlete. As an additional point that extends beyond
the current case example, while the organization of each team structure may depend on the size
and complexity of the sport organization, the main tenants of each approach would remain
consistent. In experience of the last author, professionals working in the field of sport psychology
should be aware that the collaborative structure and function of a rehabilitation team in one
organization may be different from the collaborative structure and function of a rehabilitation team
in another organization. In addition, there may be distinct advantages and disadvantages to each
approach depending on the unique context and resources available for any given case. Similarly,
even within the same organization, the collaborative structure and function of a rehabilitation team
may differ depending on a variety of factors including but not limited to athlete preference and
timeline to competition.
From Abstraction to Application—Review of the Findings
The ideas presented within this paper are the result of a comprehensive review of the sport
injury rehabilitation literature including current rehabilitation outcomes, as well as existing
theoretical paradigms and intervention literature. In conducting the review, it is evident that within
sport literature, there is an absence of evidence at the medium level of abstraction, thereby
representing an inadequate base of translational research. That fact, along with initial reports of
team-based approaches in practice which are consistent with evidence-based approaches in non-
sport rehabilitation domains (Guagenti-Tax, 2000; Karol, 2014; Körner, 2010; Melvin, 1980)
prompt our call for an examination of the medium level of abstraction in sport injury rehabilitation.
More specifically, a call for increased focus on understanding how professionals should be
deployed (i.e., multi-, inter-, transdisciplinary teams), and how to work within a team-based
approach to most effectively rehabilitate athletes from injury. By conducting such research, the
nuanced advantages and disadvantages of each approach may be elucidated, thus assisting
professionals in choosing the best practice approach for their particular case.
Next Steps in Establishing Empirical Evidence
To concentrate efforts at the medium level of abstraction, researchers and practitioners
should first employ qualitative research designs to further describe in a systematic way how team-
based approaches are being used in professional practice, and further, to situate their findings
within consistent operational definitions such as those provided within this paper. From qualitative
research findings, measures to assess team effectiveness, factors important to team processes, and
outcomes important to injury rehabilitation can be identified by those involved in the processes
(i.e., athletes, sport professionals). It is then that applied quantitative research within professional
practice can be conducted to compare the effectiveness of the team-based approaches described
within this paper. Additionally, research can then be conducted to evaluate the strengths and
weaknesses of each approach and how each approach may be impacted by the type of sport, level
of competition, and injury presentation. In light of the dearth of research within this domain, an
expansive area of inquiry exists which can be creatively explored by both researchers and
practitioners in the field of sport psychology.

Implications for Professionals in the Field of Sport Psychology
Informed by the aforementioned review and case example presented above, implications
for professional practice follow. To raise awareness of gaps in the translation of evidence to
practice and increase consciousness of the importance of team-based work, alterations to
practitioner training and education are a prudent place to begin. A critical first step is developing
practitioners who are both ideologically ready and who have developed the skills necessary to
carry out team-based work. Evidence within the general healthcare domain supports early
exposure to team-based care as an avenue for creating prepared practitioners (Carney et al., 2015).
For practitioners currently in charge of training and supervision, creating spaces which expose
trainees to interprofessional education (IPE) is paramount. Operationalized as explicit training in
how to work effectively across diverse disciplines, IPE has been linked to improved attitudes
toward collaboration, increased confidence in the workplace, and development of team-based
skills within the health care education literature (Darlow et al., 2015; Robben et al., 2012).
Although not specific to the sport domain, established training sites such as the Centre for
Interprofessional Education at the University of Toronto are an excellent resource for those
interested in implementing IPE. Additionally, practitioners can create opportunities to learn about
the elements critical to optimal team functioning (e.g., effective communication, debriefing
protocols) in their classes, model effective team-based work in their classroom structure and
pedagogy (e.g., engaging colleagues from diverse disciplines in teaching, allowing for diverse
allied health professionals to take commons courses), and promote team-based learning
opportunities in course assignments and practicum requirements.
Second, in raising awareness around the need for team-based work through education,
shifts in professional practice values and philosophy may be warranted (Poczwardowski et al.,
2004). Practitioners should examine the paradigm through which they view injury rehabilitation
(i.e., medical model, biopsychosocial model), consider the professional approach they employ in
their own practice, and review the degree of collaboration present in the interventions they deliver.
Through this examination, inconsistencies and gaps in individual practice may emerge which
should illustrate potential alterations (if any) to individual practice values and philosophy.
Third, and in responding to alterations in practice philosophy, practitioners can identify
changes to make within the context of their own work to better align with current evidence and
more effectively using the levels of abstraction in succession (i.e., high to medium to low). For
practitioners operating within a team-based approach, evaluating the effectiveness of processes
associated with team-based work such as debriefing sessions (Allen, Reiter-Palmon, Crow, &
Scott, 2018), collaborative goal-setting (Driskell, Salas, & Driskell, 2018), and communication
between professionals (Körner, 2010) may illuminate spaces for improved collaboration and team
functioning. Additionally, evaluating the role of the athlete within the rehabilitation team may
warrant efforts toward giving athletes a more consistent and valued voice in rehabilitation
planning. For practitioners operating alongside allied health professionals in their respective silos,
advocating for training to improve integration may be an important next step. Within the general
healthcare domain, training programs such as TeamSTEPPS (Lineberry et al., 2013), BOOST!
(University of Toronto Centre for Interprofessional Education, 2016), and others (Lacerenza,
Marlow, Tannenbaum, & Salas, 2018) may offer a starting place for improving collaboration. For
practitioners operating independently as solo practitioners, taking intentional steps to improve
relationships with members of their referral network may augment their practice toward a
multidisciplinary approach. In offering these diverse next steps, the authors acknowledge that
changes to professional practice are often context-dependent and therefore next steps may look
different among various professionals in the field.
Finally, regardless of context, training and skills pertinent to all practitioners have been
established as important for effective team-based work. To date, evidence from team-based
practice across a variety of disciplines supports the importance of effective communication styles
(Körner, 2010), diversity and cultural training (Bell, Brown, Colaneri, & Outland, 2018; Lie, Lee-
Rey, Gomez, Bereknyei, & Braddock, 2011), improving role clarity within a team (Howarth,
Warne, & Haigh, 2012), and forming trust between colleagues (Sinclair et al., 2009). In light of
their training and competency requirements, sport psychology professionals may be well
positioned to engage in the abovementioned practices as well as to facilitate development and
growth in these areas for their team members.
Conclusion
Given persistent suboptimal outcomes in sport injury and rehabilitation (Maffulli et al.,
2010; Öztürk & Kiliç, 2013; Rice et al., 2016; Swenson et al., 2013), there is an evident need for
an evaluation of the way in which the theories of sport injury are being integrated into practice.
To this end, within the sport injury literature, there is an absence of medium level abstraction
evidence to inform how practitioners should approach their work given a chosen theoretical
conceptualization. Furthermore, despite consistent adoption of the biopsychosocial paradigm,
interventions remain largely unidimensional, which is not surprising given the lack of emphasis
on understanding team-based approaches within sport injury. As such, a need for research at the
medium level of abstraction is paramount, alongside a critical evaluation of our individual
translation of evidence to practice.

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Figure 1: Injury rehabilitation literature organized according to levels of abstraction (Aoyagi &
Poczwardowski, 2013).
Figure 2: Rehabilitation Team Structures. MED = medical domain. ORG = organizational

domain/high performance director. PHYS = physical domain. TECH = technical domain. PSYCH
= psychological domain. Solid arrows represent frequent flow of communication. Dashed arrows
represent infrequent, or “as needed” flow of communication.

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“A Review of the Sport Injury and Rehabilitation Literature: From Abstraction to Application”

by Hess CW, Gnacinski SL, Meyer BB

Note: This article will be published in a forthcoming issue of

Section: Professional Practice

Authors: Courtney W. Hess1, Stacy L. Gnacinski2, and Barbara B. Meyer3

Affiliations: 1University of Massachusetts Boston; Department of Counseling & School

Running Head: Injury rehabilitation: Abstraction to application

Journal: The Sport Psychologist

Acceptance Date: November 21, 2018

©2018 Human Kinetics, Inc.

A Review of the Sport Injury and Rehabilitation Literature:

alongside areas for future research.

Keywords: Team Approaches, Literature Review, Evidence-Based Practice, Professional Practice

Philosophy, Translational Research

Despite consistent efforts toward improved evidence-based practice, sport injury

outcomes, researchers have pointed to a variety of institutional (e.g., models of healthcare,

insurance limitations, inconsistent professional competency requirements across professions),

rehabilitation, alongside a rapidly evolving body of intervention literature available to

To identify gaps in the translation of evidence to practice, the philosophy underpinning

first be considered. Across domains (e.g., counseling, psychotherapy, sport psychology),

intervention selection, implementation, and evaluation (Poczwardowski, Sherman, & Ravizza,

2004). Such professional philosophies are thought to be informed by theoretical paradigms,

practice approaches, and intervention techniques within boundaries of competency

conceptualization of a phenomenon. For sport injury rehabilitation, this encompasses the

biomedical and biopsychosocial paradigms, which provide a comprehensive framework for

practitioner, multidisciplinary, interdisciplinary, transdisciplinary), thereby representing a shift

conceptualization of sport injury to the most nuanced explanation of evidence-based interventions.

For example, adoption of the biomedical paradigm historically resulted in a lone-physician

as multifaceted, which necessitates application of a team-based approach to sport injury

thereby contributing to a dearth of team-based approaches employed in practice (Fiscella &

to suboptimal rehabilitation outcomes.

Theoretical Paradigms for Understanding Sport Injury

Throughout westernized medicine, the biomedical model has underpinned the

in return-to-sport guidelines, whereby an athlete’s readiness to play is predominantly assessed by

successful rehabilitation conceptualization, and intervention, as evidenced by poor return

outcomes. In turn, questions surrounding adherence to rehabilitation protocols, failure to return-

Seminal research published by George Engel (1977) prompted a shift in the

closely represented a comprehensive biopsychosocial paradigm (Wiese-Bjornstal et al., 1998).

more positive behaviors related to injury rehabilitation (e.g., compliance to rehabilitation

various model components in isolation for informing interventions aimed at improved

The biopsychosocial model of sport injury rehabilitation. The biopsychosocial model

paradigm through the inclusion of physiological influences of injury rehabilitation. In addition,

psychological, and socio-contextual factors may also interact to influence intermediate

biopsychosocial outcomes, which ultimately facilitate or debilitate rehabilitation outcomes.

Professional Practice Approaches in Sport Injury Rehabilitation

In sport, practitioners across competitive levels have provided anecdotal or professional

increased generalizability of the identified team-based approaches, evidence across a variety of

utilized in practice as evidenced by continual reports of return-to-play decisions based unitarily in

majority of return-to-play guidelines are still created solely by physiologically-focused

decisions are often made by a lone professional (Creighton et al., 2010).

presence of multiple professionals from diverse disciplines simultaneously working on outcomes

efficacy of multidisciplinary approaches to rehabilitation services across a variety of populations

and medical conditions (Griffiths et al., 2000; Khan et al., 2010).

In sport, an approach published by Clement and Arvinen-Barrow (2013) is the most

consistent with the multidisciplinary approach described previously in other rehabilitation

diverse helping professionals (e.g., athletic trainers, sport psychologists, physiotherapists,

been established as important to rehabilitation outcomes (e.g., psychological, physiological). The

dominant role in treatment. Clement and Arvinen-Barrow outlined the importance of

It is feasible that in current form Clement and Arvinen-Barrow’s multidisciplinary

multidisciplinary approach within the sport domain is lacking.

multiple professionals from diverse domains to be focused on discipline-specific work. However,

established referral networks, imploring rehabilitation team members to engage in meaningful

Similar to multidisciplinary approaches in healthcare, empirical findings support the efficacy of