Journal of Applied Sport Psychology

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Psychological interventions in sport injury

prevention and rehabilitation

Deborah Durso Cupal

To cite this article: Deborah Durso Cupal (1998) Psychological interventions in sport injury
prevention and rehabilitation, Journal of Applied Sport Psychology, 10:1, 103-123, DOI:
10.1080/10413209808406380

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JOURNAL OF APPLIED SPORT PSYCHOLOGY 10, 103-123 (1998)

Psychological Interventions in Sport Injury

Prevention and Rehabilitation
DEBORAH
DURSOCUPAL

Utah Stute Universir?,

This article reviews and critiques research on preventive and rehabilitative psy-
chological interventions for sport injury. Intervention foundations, essential pro-
gram components, theoreticakonceptual bases. supportive literature, individual
intervention studies, research strengths and weaknesses, and relevance of study
findings to future research are discussed. It is argued that psychological interven-
tion studies demonstrate preliminary evidence of treatment efficacy. A strong call
is issued for further empirical inquiry into preventive and rehabilitative injury
processes.

There are many aspects to the occurrence of and recovery from sport
injury. Until the last decade, however, interventions usually addressed the
physiological dimensions of sport injury to the exclusion of psychological
dimensions (Petitpas & Danish, 1995). Recently, however, the sports med-
icine community has become increasingly aware of the integral role that
psychosocial factors play in the injury Occurrence and recovery processes
(Brewer, Jeffers, Petitpas, & Van Raalte, 1994).
Most physically active individuals find it difficult to avoid injury. Over
17 million sport injuries are reported annually in the United States alone
(Booth, 1987). with incidence of injury increasing among intercollegiate
athletes (Meeuwisse & Fowler, 1988). Injury exerts a direct impact on an
athlete’s psychological well-being, which in turn, directly influences
health, performance, and the risk of further physical injury (Heil, 1993).
Unfortunately, athletes currently still follow a course of prevention or
rehabilitation that concerns itself primarily with the physical aspects of
injury (Mainwaring, 1993). Often omitted is intervention that facilitates

The author wishes to thank Britton Brewer for his review of earlier drafts of this manu-
script.
Correspondence concerning this article should be addressed to Deborah D. Cupal, De-
partment of Psychology, Utah State University, Logan, Utah 84312-28 10. Electronic mail
may be sent via Internet to dcupal@xmission.com.

103 l04l-3200198/01034)1235I OQM

Copynghr 1998 by Associalion fcf Advancement of Applied Sporl Psychology
All nghrs of reproduction in any form reserved
104 CUPAL

injury prevention or coping with an injury’s accompanying threat to self-

concept, beliefs, commitments, values, and socidernotional functioning
(Danish, 1986; Hardy & Crace, 1993; Steadman, 1993). Yet sufficient
empirical evidence exists that unnecessary injuries occur and that recov-
ery is compromised because of failure to address psychological factors
(Andersen & Williams, 1993; Faris, 1985; Heil, 1993; Ievleva & Orlick,
1991).
A paucity of empirical studies that include control groups, standardized
prevention and rehabilitation protocols, and/or specific injury orientations
serves to cloud the issue of how significantly psychological interventions
contribute to prevention of and recovery from injury (Durso-Cupal,
1996). It is still unclear how profoundly psychological factors affect re-
covery from injury; prevalence and severity of psychological disturbance
in sport injury rehabilitation settings have yet to be adequately assessed
(Brewer, Linder, & Phelps, 1995). Even more sparsely investigated have
been the affective components of injury prevention interventions (Ken &
Goss, 1996). Moreover, the question of why some individuals struggle
more than others with psychological aspects of the recovery process, as
manifested in increased levels of frustration and pain, loss of motivation
to perform physical therapy, and elevated anxiety, has been largely un-
answered (Udry, 1995). Additionally, questions regarding whether the
competitive athlete can remain injury free or what multivariate compo-
nents comprise coping also lack empirical answers.
To date. only 4 empirical prevention and 13 empirical rehabilitation
psychological intervention studies have been conducted (see Tables 1 and
2). Consequently, there is only a preliminary understanding of the com-
plex interplay of psychological and physiological variables that contribute
to prevention and rehabilitation of sport injuries. The purpose of this
paper is to review and critique injury intervention research conducted to
date, and to highlight the importance of these studies’ findings in an effort
to further subsequent intervention endeavors.
The Nature of Interventions
A number of guidelines for psychological interventions have been of-
fered, including specific treatments that focus on the role of mental prac-
tice techniques (e.g.. Heil, 1993; Rotella & Heyman, 1993; Wiese &
Weiss, 1987). The fundamental goal of intervention, however, is to iden-
tify the subjective cost of injury to an athlete while concurrently teaching
and strengthening coping resources (Heil, 1993; Ross & Berger, 1996).
Interventions should consider the personal meaning of injury, as well as
empower an individual with appropriate recovery or preventive strategies.
Injury intervention is currently succeeding as an adjunct to established
performance or physical rehabilitation programs. A small body of re-
search in the area of imagery and healing of injuries suggests that a
structured physical rehabilitation program that includes some form of im-
agery is more effective in influencing the extent to which an individual
will heal than physical rehabilitation alone (Brewer et al., 1994; Faris,
 Table 1
Sport injury prevention intervention studies
Control Statistical
Study N Population Intervention group(s) Method Intervention effects comparisons
May & Brown 18 Olympic alpine relaxation/ No Qualitative reduced injuries; No
(1989) skiers imagery/ increased self-confidence
counseling and self-control
Schomer (1990) 10 marathon runners attentional No Qualitative facilitated heavy training No
strategies without injury
Davis (1991) 21 collegiate stress No Quantitative 52% reduction in No
swimmers/ management swimming injuries;
football players 33% reduction in
football injuries
Kerr & Goss (1996) 24 elite gymnasts stress Yes Qualitative/ reduced injuries and Yes
management Quantitative stress levels

c
E:
106 CUPAL

1985; Ievleva & Orlick, 1991). Recent findings demonstrate that a com-
prehensive plan that interfaces certain external physiological procedures
with internal states of mind results in enhanced preventive and rehabili-
tative outcomes (Davis, 1991; Draper & Ballard, 1991; Durso-Cupal,
1996; Kerr & Goss, 1996; Levitt, Deisinger, Wall, Ford, & Cassisi, 1995;
May & Brown, 1989; Ross & Berger, 1996; Rotella & Campbell, 1983).
It follows, then, that interventions should include components com-
prising a treatment program of proactive steps that identify and validate
personal and situational injury factors (Heil, 1993). Ideally, these will be
grounded in empirical theory and be comprised of variables that have
been shown to positively contribute to prevention or physical recovery.
At present, there are five such psychologicallpsychosocial components
common across injury intervention studies; these components include
goal setting, psychological skills training, positive self-talk, knowledge/
education, and social support (Durso-Cupal, 1996).
TheoreticaYConceptuaI Bases of Psychological Interventions
It has been common practice to separate theoretical foundations of sport
injury interventions into investigations concerned with (a) antecedents of
injury, (b) effects (consequences) of injury, and (c) psychological recov-
ery factors (Heil, 1993). Empirical investigations, however, are beginning
to reflect the multivariate influence of psychobiological factors inherent
in the injury recovery process (Petitpas & Danish, 1995). The interaction
of psychological variables not only explains and predicts affective re-
sponses to injury, but also plays an integral role in mediating adjustment
to and recovery from athletic injury (Ross & Berger, 1996).
Although early intervention efforts were based on adaptations of stage
models of grief and loss (e.g., Astle, 1986; Lynch, 1988; Rotella, 1983,
cognitive appraisal models (e.g., Andersen & Williams, 1988; Gordon,
1986; Lazarus & F o l h a n , 1984) have recently been found beneficial in
directing prevention and/or rehabilitation interventions (Brewer, 1994). In
general, stage models have presented difficulties in generalizing across
individual athlete responses. Because cognitive appraisal models rest on
the premise that an athlete’s interpretations of injury are critical to un-
derstanding individual differences in emotional reactions to injury (Ross
& Berger, 1996). these models are particularly applicable to the amelio-
ration of associated emotional and physical distress/dysfunction.
Theoretical bases for implementation of psychological interventions for
sport injuries owe much to the earlier stress research of Allen (1983) and
Smith (1979). among others. Psychological injury prevention and reha-
bilitation approaches have evolved from a synthesis of the stress-illness,
stress-injury. and stress-accident literatures. Current sport injury interven-
tions appear to be conceptually and theoretically based primarily on an
amalgam of models advanced by Andersen and Williams (1988). Cohen
and Wills (1985). Lazarus and Folkman (1984). Moos and Tsu (1977).
and Weiss and Troxel (1986). Wiese-Bjornstal and Smith (1993) have
contributed significantly to a theoretical foundation for psychological in-
 Table 2
Sport injury rehabilitation intervention studies
Control Intervention Statistical
Study N Population Intervention group(s) Method effects comparisons
Sprenger, Carlson. & 1 meniscal surgery biofeedback No Quantitative increased ROM No
Wessman ( 1979)
Krebs (1981) 26 meniscal surgery biofeedback Yes Quantitative increased EMG output;
increased strength
Rotella & Campbell 1 basketball player systematic No Qualitative reduced reinjury anxiety;
(1 983) desensitization increased confidence
Wise. Fiebert, & Kates 6 patellofemoral pain biofeedback No Quantitative reduced pain; return to sport
( 1984) functions
Draper ( 1 990) 22 ACL reconstruction biofeedback Yes Quantitative increased strength; increased
ROM
Draper & Ballard 30 ACL reconstruction biofeedback Yes Quantitative increased strength Yes 3
(1991)
Carroll (1993) 6 mixed injuries imagery Yes Quantitative improved mood; return to Yes
sport activities
Nicol ( I 993) 1 strain injury imagery/ No Qualitative pain reduction; improved No
hypnosis/ mood
counseling 5
Sthalekar (1993) 1 waterskier imagery/ No Qualitative pain reduction; some ROM No
(paralysislpain) relaxation/ recovery
hypnosis
Brewer, Jeffers. 20 mixed injuries goal setting/ No Quantitative/ positive perceptions of Yes
Petitpas, & Van imagery/ Qualitative interventions; preference for
Raalte (1994) counseling goal setting; improved
c
attitude toward rehabilitation
 Table 2
Continued
Control Intervention Statistical
Study N Population Intervention group(s) Method effects comparisons
~~ ~~

Levitt. Deisinger. Wall. 5 I arthroscopic knee EMG biofeedback Yes Quantitative greater extensor torque & Yes
Ford, t Cassisi ( 1 995) surgery-mixed quadriceps fiber recruitment at c1
injuries 2 weeks postsurgery s
Durso-Cupal (1996) 30 ACL reconstruction relaxation/ Yes Quantitative/ increased strength; increased Yes F
guided imagery Qualitative extension; reduced state &
reinjury anxiety; quicker
return to activities
Ross & Berger (1996) 60 male-arthroscopic stress-inoculation Yes Quantitative reduced anxiety; reduced Yes
meniscal surgery training pain; increased physical
functioning
 PSYCHOLOGICAL INTERVENTIONS 109

terventions with their integration of the Andersen and Williams (1988)

preinjury psychosocial model with the Wiese and Weiss (1987) stress
model of injury. This paradigm offers a pragmatic framework from which
to address postinjury concerns. Theoretical rationales for injury interven-
tions have also been offered, for example, by Danish, Petitpas, and Hale
(1992), Duda, Smart, and Tappe (1989). and Mainwaring (1993).
A discussion of conceptual and theoretical issues would be remiss with-
out mention of a few nonintervention, injury self-report studies. Ievleva
and Orlick (1991) were among some of the first researchers to examine
relationships between psychological variables and physical recovery rates
among athletes with knee and ankle injuries. In a retrospective survey
study, they found positive correlations with recovery rates for goal setting,
positive self-talk, and healing mental imagery. Athletes who were satisfied
with their rehabilitation and who had recovered most quickly had applied
these mental skills without specific instruction during their recovery. In
a follow-up study to Ievleva and Orlick (1991). Loundagin and Fisher
( 1993) retrospectively surveyed athletes recently recovered from knee and
ankle injuries to investigate the relationship of mental skills to injury
rehabilitation. Their results indicated goal-setting, healing mental
imagery, and focus of concentration as most highly related to faster heal-
ing rates. Both quantitative and qualitative results supported integration
of mental skills training and injury rehabilitation programs, particularly
for those skills that facilitate locus of control.
Latuda and Richardson (1995) compared differences between expected
and actual healing rates and certain mental skills from responses by in-
tercollegiate athletes. When holding severity of injury constant, results
indicated nonsignificant correlations between healing time and use of im-
agery, self-talk, goal-setting, and relaxation. Results from qualitative data,
however, revealed that athletes who successfully rehabilitate tend to self-
engage in mental skills such as positive self-talk and goal setting. This
research illustrates the need to operationalize definitions of mental skills,
combine quantitative and qualitative inquiry, and investigate the differ-
ence in injury rehabilitative outcomes when mental skills are taught and
practiced as part of an intervention versus when performed informally by
athletes on their own.
Bond, Miller, and Chrisfield (1988) were among the first to empirically
investigate the relationship between injury prevention and psychological
variables. Although an unexpected negative correlation was discovered
between high attention control scores and swimming injuries for colle-
giate swimmers, this study demonstrated the critical importance of op-
erationalizing injury definitions, reporting injury incidence accurately, and
matching psychological assessments appropriately to type of injury or
sport in order to obtain accurate outcome data. Collectively, the Bond et
al. (1988), Ievleva and Orlick (1991), Latuda and Richardson (1995). and
Loundagin and Fisher (1993) studies laid important ground work for pre-
ventive and rehabilitative intervention with respect to research design,
analysis, treatment, measurement, and application.
110 CUPAL

Studies of Prevention and/or Rehabilitation Interventions

In contrast to the rich body of empirical studies investigating psycho-
logical factors in sport injury occurrence and rehabilitation, there is a
dearth of controlled intervention studies examining relationships among
emotional antecedents, responses, consequences, and physiological out-
comes of sport injury. Unfortunately, psychological injury intervention
research has not kept pace with the development of theoretical models.
Nevertheless, empirical investigations of interventions focused on the pre-
vention or rehabilitation of sport injuries are beginning to accumulate.

Prevention Interventions
May and Brown’s ( 1989) preventionhehabilitation program applied a
broad-spectrum systems theory approach to the delivery of injury inter-
ventions. Cognitive, behavioral, and humanistic frameworks were used
with individual, dyadic, and group modalities to intervene with such tech-
niques as attention control, imagery, and other mental practice skills.
Working with U.S. alpine skiers in the Calgary Olympics, May and
Brown reported reduced injuries, increased self-confidence, and enhanced
self-control as a result of prevention efforts. Much of the success of the
program appears to be attributable to the comprehensive nature of injury
prevention (i.e., mental skills training, crisis intervention, team building,
communication, relationship orientations, and specific injury prevention
[and rehabilitation] activities).
Investigating the effects of associative versus dissociative thought pat-
terns with marathon runners, Schomer (1990) reported an ability to op-
timize training intensity without increasing injury. Intervention involved
shaping associative thought processes over a five-week training period
using audio tapes of attentional strategies with a resulting convergence
of increased associative thinking and perceptions of increased training
effort. Through the use of light-weight recorders worn on the body during
training, this study used a simple, yet effective method to shape atten-
tional strategies to produce optimal, injury-free performance.
Davis (1991) focused on prevention treatment (stress management) us-
ing imagery with collegiate swimmers and football players to reduce in-
juries. Combining progressive relaxation with imagined rehearsal of re-
lated sport skills, Davis approached prevention from a stress-intervention
orientation. Although fraught with logistical problems relative to delivery
of services to these two populations, Davis reported a 52 percent reduc-
tion in swimming injuries and a 33 percent reduction in football injuries.
These findings raise important questions concerning specification of in-
jury etiology, methods of injury data collection, the nature of the stress/
injury relationship, and the need to identify types of interventions that
hold potential to reduce injuries.
Most recently, the Kerr and Goss (1996) stress-management prevention
study with elite gymnasts, (which was based on Meichenbaum’s stress
inoculation training), reported a decrease in both injuries and levels of
 PSYCHOLOGICAL INTERVENTIONS 111

athletic stress. Intervention group participants completed 16 stress-man-

agement sessions, while members of the control group completed only
stress and injury assessments. Reporting of injuries focused on gymnasts’
perceptions of injury more than objective injury measures. Although in-
juries for the intervention group decreased during an eight-month period,
injuries for the control group increased during this same time period.
Stress levels for the intervention group were reduced significantly more
than for members of the control group. Findings from this study reinforce
observations from previous research that psychosocial stress contributes
to the experience of injury and that interventions targeted toward reduc-
tion of sport stress, as well as life stress, can be effective in preventing
injury.
Rehabilitation Interventions
With the exception of four studies, research involving rehabilitative
interventions with controlled treatment conditions and quantitative out-
come measures have been documented in the sport injury literature only
within the past decade. As early as 1979, Sprenger, Carlson, and Wessman
( 1979) intervened with biofeedback following medial rneniscectomy to
increase motivation, muscle strength, pain tolerance, and flexibility. Krebs
(198 1) also used electromyographic feedback for individuals following
meniscectomy in an experimental analysis, with resulting increased EMG
output and improved muscle strength. In a pioneering sport psychology
study, Rotella and Campbell (1983) detailed the methods of systematic
desensitization as a procedure that ameliorated reinjury anxiety as well
as facilitated injury recovery. In a case study of an injured female bas-
ketball player, they offered pragmatic suggestions relative to conducting
a program of systematic desensitization as part of a sport injury rehabil-
itation program. Wise, Fiebert, and Kates (1984) used a three-phase elec-
tromyographic biofeedback and exercise program with athletes with pa-
tellofemoral-pain symptoms, altering vastus medialis oblique activity to
decrease pain.
Recent rehabilitative intervention studies have expanded treatment mo-
dalities to include guided imagery, relaxation, stress-inoculation, and goal
setting, in addition to biofeedback. Draper (1990) and Draper and Ballard
(1991) investigated the efficacy of electrical stimulation versus electro-
myographic biofeedback in the recovery of quadriceps femoris muscle
function following anterior cruciate ligament surgery. In both studies,
Draper reported significantly greater recovery of percentage of peak
torque for athletes in the experimental group (biofeedback) than for those
in the electrical stimulation group. Sthalekar (1993) provided imagery and
hypnotic relaxation in a single-subject design for a partially paralyzed
waterskier with resulting outcomes of pain reduction, increased range of
motion, and increased self-esteem. Nicol (1993), who also used a single
subject design, reported reduced pain and inflammation for a severe strain
injury using imagery, relaxation, counseling, and hypnosis in close co-
operative efforts with medical personnel.
112 CUPAL

Although operating from informal intervention protocols, other studies

offer useful suggestions for effective components of an irnagery/relaxa-
tion rehabilitative intervention. Carroll (1993) investigated the influence
of mental practice with six collegiate athletes (mixed injuries) with relax-
ation and guided imagery. Using case-study techniques with a small sam-
ple that included a control group, the findings reflected enhanced recovery
and reduced mood disturbance for some athletes. Brewer et al. (1994)
investigated injured athletes' perceptions of counseling, goal setting, and
imagery interventions. Their findings indicated positive athlete percep-
tions for all three intervention strategies.
The most recent rehabilitative intervention studies have used traditional
control group designs. Levitt, Deisinger, Wall. Ford, and Cassisi (1995)
investigated the effectiveness of ambulatory biofeedback (EMG) on gains
in extensor torque and quadriceps muscle fiber with athletes following
arthroscopic knee surgery. Biofeedback intervention produced greater ex-
tensor torque and quadriceps muscle fiber recruitment two weeks post-
surgery. Operating from a cognitive-behavioral intervention orientation,
Ross and Berger's (1996) study examined the effects of stress inoculation
training for male athletes undergoing arthroscopic meniscal surgery. Ath-
letes in the treatment group reported significantly less postsurgical pain
and anxiety and required fewer days to return to physical functioning than
individuals in the control group. Investigating the efficacy of mental-skills
training for recovery from ACL reconstruction, Durso-Cupal (1996) pro-
vided sessions of relaxation and guided imagery (designed and imple-
mented to parallel physical rehabilitation protocols). Outcomes at 24
weeks postsurgery revealed significantly greater gains in strength and
degrees of extension, as well as significant reductions in reinjury and state
anxiety, and a quicker return to desired activities, for intervention group
members than for members of the other two groups.
Strengths and Weaknesses of Current
Intervention Studies
These 17 studies reflect a number of theoretical and, in particular, meth-
odological strengths and weaknesses. Nearly all prevention and interven-
tion studies have linked theoretical models of injury to psychological
outcomes, reflecting either a stage or cognitive appraisal model orientation
while investigating personal or situational psychological factors. Brewer
et al. (1994), Davis (1991), Durso-Cupal (1996). Kerr and Goss (1996).
May and Brown (1989), Nicol (1993). Ross and Berger (1996). and Ro-
tella and Campbell (1983) acknowledged the joint influence of personal
and situational psychological factors; the Durso-Cupal study reported out-
comes in terms of this synergistic effect.
All interventions demonstrated positive outcomes as a result of the
preventive or rehabilitative endeavors. Preventive interventions, at the
very least, reduced injuries, and in most cases improved mood, optimized
sport effort, and reduced stress. In all rehabilitative interventions with
control groups, greater recovery of physical strength, as well as reduced
 PSYCHOLOGICAL INTERVENTIONS 113

anxiety and pain, were achieved for intervention group members versus
control group members. Regardless of intervention modality, be it stress-
management training (Davis, 1991; Kerr & Goss, 1996; Ross & Berger,
1996), relaxatiodguided imagery/goal setting (Brewer et al., 1994; Car-
roll, 1993; Durso-Cupal. 1996; May & Brown, 1989; Nicol, 1993; Sthal-
ekar, 1993). attentional strategies (Schomer, 1990). systematic desensiti-
zation (Rotella & Campbell, 1983). or EMG biofeedback (Draper, 1990;
Draper & Ballard, 1991; Krebs, 1981; Levitt et al., 1995; Sprenger et al.,
1979; Wise et al., 1984), psychological intervention made a statistically
significant difference for the recovering athlete in terms of one or a com-
bination of the following outcomes: earlier strength gains, increased phys-
ical functioning, and reduced pain, state anxiety, and reinjury anxiety.
Although results from these studies offer evidence of intervention ef-
ficacy, they reflect several methodological problems. The first of these
concerns a lack of control groups in all but one of the prevention studies
and five of the rehabilitation studies. Only 1 of the 17 intervention studies
included a placebo-control group (Durso-Cupal, 1996). Without adequate
controls, which includes assessing the impact of potential placebo effects
in psychological intervention, it is difficult to separate treatment effects
from effects of other intervening variables. This weakness applies equally
to both biofeedback interventions and the more clinical psychology-ori-
ented interventions. Without such comparisons, the effects of exercise or
attention, for example, cannot be accurately separated from the treatment
effect. Although Levitt et al. (1995) did not include a placebo group in
their study, they astutely called for the inclusion of feedback with a pla-
cebo control group in future interventions. There is sufficient preliminary
evidence from these studies as to the possibility of physician and/or cli-
nician iatrogenic effects influencing physiological and psychological out-
comes.
For those studies that do include control groups, a second method-
ological issue arises concerning preintervention group equivalence. Two
related, yet distinctly different subissues are pertinent to the subject of
group equivalence. One of these concerns randomization of subject as-
signment, and the other relates to group member physiological similarity,
that is, biomechanical equivalence among individual athletes in any one
study group. In the first instance, some studies have used assignment
procedures based on geography, gender, subject preferences, or motivation
(e.g., Kerr & Goss, 1996). Procedures of this sort threaten the internal
validity of studies that use them. Moreover, although assumptions of
group equivalence may appear to have been met statistically, convenience
samples often display the tendency to exhibit self-selection effects, thus
compromising external validity. In other words, those who agree to par-
ticipate in the intervention groups may be more motivated to recover,
even though preliminary analyses indicate that the groups are equivalent
on psychosocial andor psychological variables prior to treatment. Addi-
tionally, there are sometimes confounding factors that impede attainment
of preintervention group equivalence, such as exposure to varying coach-
114 CUPAL

ing styles, different physical therapists, or different surgeons for individ-

uals (e.g., Durso-Cupal 1996). The influence of these nonrandomized fac-
tors present potential for inaccurate assumptions regarding treatment
effects.
The second issue pertaining to group equivalence may be unavoidable
in cases of injury involving surgical procedures, particularly knee surgery.
Current medical opinion suggests that the knee, for example, is biome-
chanically altered by surgery (Mainwaring, 1993).Presurgical muscle per-
formance characteristics, therefore, may be invalid. Some ways to assure
physiological group equivalence is to evaluate the uninvolved limbs’ mus-
cle performance characteristics, investigate only one type of injury per
study, and/or include self-report measures of both presurgery and post-
surgery activity levels. Four of the six surgical studies included some or
all of these procedures to facilitate group equivalence (Draper, 1990; Dra-
per & Ballard, 1991; Durso-Cupal. 1996; Ross & Berger. 1996).
For any single intervention, it is difficult to construct a design that
thoroughly addresses problems of generalizability, whether in terms of
gender, type of athlete, type of injury, definition of injury, or type of
intervention. Credibility of results, however, comes into question when
claims of generalizability are extended to dissimilar populations, and/or
support is offered for these generalizations in the form of references that
are not relevant to that study’s population (e.g., generalizing findings from
a healthy population to an injured population or vice versa). Authors of
most of the 17 preventive and rehabilitative studies, however, have not
offered generalizations beyond their respective samples. Biofeedback
studies have been more likely to generalize from or to healthy popula-
tions, compare isokinetic with isometric assessments, or conclude that
EMG biofeedback was more efficacious than electrical stimulation or ex-
ercise without adequate control groups (e.g., Draper, 1990; Draper & Bal-
lard, 1991).
Other problems include nonstandardized treatment or assessment mea-
sures (Carroll, 1993), nonblind examiners (Ross & Berger, 1996). and
dual-role conflicts arising when the investigator providing intervention
also measures participants’ responses (Durso-Cupal, 1996). Nearly all
studies contain one of these methodological problems. Eight studies have
reported outcomes without statistical significance testing, either as per-
centage or amount of improvement (e.g.. Davis, 1991). or as a case-study
(e.g., Rotella & Campbell, 1984). Of course, case-study designs do not
preclude statistical significance testing. n o studies have included effect
size calculations as an adjunctive, statistical interpretive tool for small
sample sizes (Durso-Cupal, 1996; Kerr & Goss, 1996). A few biofeedback
studies (e.g., Draper, 1990; Draper & Ballard, 1991) failed to include
instrumentation measurement error in their analyses. Unfortunately, ap-
plying nonstandardized levels of treatment and omitting measurement er-
ror in calculations of statistical significance data hold potential for con-
founding instrumentation and treatment effects.
Certainly a major strength for 10 of the intervention studies is the
 PSYCHOLOGICAL INTERVENTIONS 115

utilization of homogeneous (similar injury) samples of injured athletes

(Davis, 1991; Draper, 1990; Draper & Ballard, 1991; Durso-Cupal, 1996;
Krebs, 1981; Nicol, 1993; Ross & Berger, 1996; Rotella & Campbell,
1983; Sprenger, et al., 1979; Sthalekar, 1993). Homogenous groups are
useful in limiting confounding influences (e.g., separating injury severity
from injury duration), particularly when established physical rehabilita-
tion protocols are involved. Programs of physiotherapy respond to con-
stantly improving surgical techniques. When physical rehabilitation pro-
tocols and accompanying recovery benchmarks change to keep pace with
these new medical techniques, they tend to exacerbate difficulties in sort-
ing out confoundings, as in the Draper (1990) and Draper and Ballard
(1991) studies. This often results in problems of generalizability when
the sample is not homogenous with respect to injury.
Injured athlete perceptions of medical and psychological intervention
offer important information for sport injury intervention research. A
strength of a few of the intervention studies is the correlation of these
perceptions with actual outcomes, a practice that is useful for designing
effective interventions (including creating programs harmonious with
medical and sport team settings). The Nicol (1993). Brewer et al. (1994).
and Durso-Cupal (1996) studies included questions in the intervention
format designed to elicit such perceptions. In the case of the latter two
studies, responses to these questions were then correlated either with pref-
erence for type of intervention and/or effectiveness of specific interven-
tion components. Results of the Durso-Cupal study indicated that tech-
niques and/or components that enabled the athletes to perceive themselves
as active agents in their recovery contributed most significantly to better
physiological outcomes.
Viewed as both a strength and weakness in some of these studies is
the design and application of psychologicallpsychosocial assessments
without established reliability and validity (e.g., “Intervention Perceptions
Questionnaire,” Brewer et al., 1994; “Athletic Experiences Survey,” Kerr
& Goss, 1996). Inferences from responses on these instruments should
be made cautiously due to potential problems with construct, content, and
criterion validity (Worthen, Borg, & White, 1993). However, when new
instruments are used in combination with well-validated tests, there exists
the potential for development of assessment measures that can more ac-
curately and specifically identify psychological factors involved in injury
occurrence and recovery. The establishment of validity should be a cu-
mulative, careful process. If predicated on concurrent and subsequent ap-
propriate investigative and confirmatory procedures such as factor anal-
yses, reliability testing, and correlational analyses, such new instruments
hold potential for better elucidating those psychological and psychosocial
factors most important to injury interventions.
These 17 studies reflect a wide variety of intervention formats. Ac-
cordingly, it is essential for researchers to include descriptions of session
content, or treatment protocols such as those provided in the Kerr and
Goss (1996) and Durso-Cupal (1996) studies. Without schedules or pro-
116 CUP&

tocols, it becomes difficult to evaluate and replicate the interventions. In

order to establish reliability and validity, confirm bases for theoretical
models, and design effective, preventivdrehabilitative interventions, de-
tailed information on content and implementation of interventions studied
is necessary.
As in the field of psychology in general (Bergin & Garfield, 1994).
these prevention and rehabilitation interventions reflect a clear trend to-
ward the practice of brief forms of clinical intervention. The variety of
brief therapies has increased greatly with particular growth in different
cognitive-behavioral and psychodynamic brief therapies. Investigators of
psychological intervention in the context of sport injury have examined
brief. effective empirical interventions, which is particularly noteworthy
in view of the necessity for the practitioner to be expediently effective in
busy sports medicine and sport performance settings.
It is difficult to evaluate the theoretical soundness of one treatment
modality over another, particularly when the vast majority of all psycho-
logical therapy studies, by virtue of their design, have not been able to
detect differences among alternative treatments (Bergin & Garfield,
1994). Perhaps one of the greatest theoretical strengths of the majority of
these intervention studies is that they have not attempted to oversimplify
the complex issues and questions relative to the interface of treatment
methods and outcomes. No preventive or rehabilitative injury intervention
study has proposed a univariate approach to injury prevention or recov-
ery, nor suggested the ubiquitous efficacy of one treatment modality over
another. The interventions vary widely with respect to processes pre-
sumed to mediate injury; the common theoretical core relies on cognitive
interpretation.
These 4 prevention and 13 rehabilitation studies acknowledge that
thinking plays a major role in the etiology and maintenance of psycho-
logical factors contributing both positively as well as detrimentally to
injury occurrence and recovery. In approaching injury from cognitive-
behavioral orientations, interventions have attempted to reduce distress
by changing beliefs and providing new information processing skills. As
proffered by Hollon and Beck (1994). these orientations are at least equal
or superior to alternative psychosocial or pharmacological approaches,
producing longer lasting change than alternative approaches.
What will be helpful in the future, however, will be the development
and implementation of interventions that not only acknowledge the per-
sonal, situational, and biological complexities of injury, but also attempt
to organize a diversity of modalities, theories, and outcomes under a few
select theoretical umbrellas. In this manner, the integrity of varying ap-
proaches can remain intact, and results can be more accurately compared
across studies.
Importance of Study Findings to Preventive and
Rehabilitative Interventions
The most obvious importance of the findings from these intervention
studies is that positive outcomes were achieved as a result of preventive
 PSYCHOLOGICAL INTERVENTIONS 117

or rehabilitative interventions. On the whole, these interventions reduced

injuries, enhanced recovery, improved mood, optimized sport effort, and
reduced pain, stress, and anxiety. Cognitive appraisal models appear to
be useful for guiding empirical efforts, accounting for individual differ-
ences in coping with sport injury, and directing actual intervention tech-
niques. The success of biofeedback techniques demonstrates the mind-
body connection and paves the way for better acceptance of cognitive
preventive and rehabilitative efforts due to the observable, concrete nature
of the intervention.
Results from these 17 studies are beginning to furnish the sports med-
icine and sports performance community with workable assumptions con-
cerning sport injury prevention and rehabilitation, assumptions that are
holistically grounded in the multivariate influences involved in injury oc-
currence and recovery. This is particularly opportune at a time when
changes in health care management necessitate that an injured individual
follow an expedient course of recovery. Although the sports medicine
community is seeking ways to help athletes deal with consequences of
injury, it is still, for the most part, reticent to embrace the need for psy-
chological preventive or rehabilitative intervention for the “average” in-
jured athlete. Positive outcomes from these empirical studies, using a
variety of intervention modalities with a diversity of injuries, provide
preliminary evidence that psychological interventions can help to prevent
injury and facilitate recovery. Moreover, the research relationships de-
veloped with sports medicine personnel as a function of these studies
have initiated positive, professional working foundations (Brewer, Van
Raalte, & Linder, 1991; Durso-Cupal, 1996). Credibility of treatment is
established when fewer athletes sustain injuries, as well as when those
who are injured return to the competitive arena more quickly and confi-
dently.
As best can be determined from results of the 11 intervention studies
that applied cognitive strategies, athletes expressed preferences for and
responded most favorably to intervention formats that included relaxation,
guided imagery, and/or goal setting. Athletes who used psychological
skills training in the interventions tended to see themselves as active
participants in the recovery process. Of course, the very nature of the
biofeedback process also intimately involves athletes in contributing to
and regaining control over their bodies. Findings from these intervention
studies, therefore, have reinforced control as a critical component of in-
jury prevention and rehabilitation-a component often inadvertently over-
looked by surgeons, physical therapists, coaches, and physical trainers
(Davis, 1991; Durso-Cupal, 1996; Kerr & Goss, 1996; May & Brown,
1989; Nicol, 1993; Ross & Berger, 1996; Rotella & Campbell, 1983;
Schomer, 1990; Sthalekar, 1993; Wise et al., 1984). Study outcomes have
confirmed injury severity, mood, goal setting, personality, social support,
and imagery as salient variables in injury intervention.
No direct linkages between guided imagery and healing have been
firmly established, but findings from prevention and intervention studies
118 CUPAL

that used mental practice techniques lay an essential groundwork for fur-
ther investigation of this potential. It should be remembered that affective
and somatic reactions to injury are generally global and varied from in-
dividual to individual-unique athlete perceptions and reactions produce
different outcomes. It appears that cognitive processes contribute the
greatest variance to reactions to injury, and that to ignore the role of
mental factors in injury prevention or physical recovery is to conduct
incomplete intervention. When building on previous work with medical
populations, sport psychology practitioners are well advised to conduct
more in-depth, empirical explorations into the imageryhealing connec-
tion. Sound research practices, including the use of placebo groups, pro-
spective longitudinal designs, and appropriate statistical analyses are par-
ticularly critical when investigating the causal path from mental practice
to injury prevention or physiological healing.
Recommendations for Research
Design
More experimental and quasi-experimental intervention studies are
needed using control groups, prospective and longitudinal approaches,
and physiological outcome measures (Durso-Cupal, 1996; Snyder-Mack-
ler, 1991). This does not preclude implementation of qualitative methods.
Causal relationships should not be inferred from correlational data. Future
studies should include larger sample sizes, matched participants, homog-
enous populations, and randomization to control for extraneous variables
that can affect treatment. A good rule of thumb is to design studies such
that threats to internal validity that cannot be controlled are randomized,
and those that can be controlled are eliminated (Worthen, Borg, & White,
1993). As well, levels of treatment for further studies should be varied
so as to better assess effectiveness of treatment (Heil, 1993), and to match
the most efficacious treatment to individual athlete needs (Bergin & Gar-
field, 1994).
Analysis
Although tests of significance provide useful ways of assessing the
relative likelihood that a real difference exists, they still have limited
utility. Particularly in a small sample, important differences may be over-
looked or exaggerated because statistical significance is a product of both
treatment effect and sample size (Worthen, Berg, & White, 1993). Be-
cause calculations with standard mean differences are not dependent on
sample size, they are one way of uncovering andor confirming differ-
ences between groups with small underlines. Effect sizes can provide an
estimate of where the average participant in the treatment group scores
with respect to a distribution of comparable participants who did not
receive the treatment (Shaver, 1993).
Theory
There is a need to increase efforts to establish sound, theoretical foun-
dations in order to expand the knowledge base concerning psychological
 PSYCHOLOGICAL INTERVENTIONS 119

intervention for sport injury (Brewer, 1994). Some ways to facilitate such
foundations are to consistently operationalize definitions, develop stan-
dardized delivery protocols, specifically test and build on established the-
ories, and empirically test hypotheses, particularly with a combination of
psychological and physiological outcome variables (Durso-Cupal, 1996;
Petitpas & Danish, 1995). There is a need to investigate specific inter-
vention components so as to examine their relative contributions to pos-
itive outcomes (Garfield, 1994; Hollon & Beck, 1994).
Measurement
Standardized assessment instruments should be used where applicable.
It is desirable to strike a balance between developing instruments that are
specific enough to retain relevance for the population of interest, yet not
so specific that they can be used only with narrowly defined populations
(Bond et al., 1988; Heil, 1993). Instrument validity and reliability should
be established through correlational studies, factor analyses, and replica-
tion (Crocker & Algina, 1986).
Recommendations for Practice
Practitioners should consider approaching psychological interventions
for sport injury prevention and rehabilitation from an established protocol
basis (Kazdin, 1994). Psychological interventions should be used as ad-
juncts to established physical training and/or rehabilitation programs to
promote treatment acceptance and effectiveness. When interventions are
orchestrated as an integral piece of the injury puzzle with the sports med-
icine team, professional relationships with physical training and medical
providers are promoted (Heil, Bowman, & Bean, 1993).
Psychological injury interventions should further explore the efficacy
of mental skills training for recovery. In particular, imagery and biofeed-
back should be used in preventive and rehabilitative interventions to test
hypotheses and identify curative factors (Ross & Berger, 1996; K e n &
Goss, 1996; Durso-Cupal, 1996; Green, 1993). Whether implementation
of mental skills in interventions is aimed at preventive or ameliorative
outcomes, potentially influential factors such as body image, locus of
control, personal meaning of injury, and gender should be considered
(Brewer, 1994; Davis, 1991; Ennler & Thomas, 1990; Ievleva & Orlick,
1991; Latuda & Richardson, 1995; Loundagin & Fisher, 1993; May &
Brown, 1989; Rotella & Campbell, 1983; Schomer, 1990; Wollman,
1986).
Preventive and rehabilitative interventions encompass the gamut from
educational issues to psychotherapy. Practitioners need to be prepared to
offer a comprehensive package adapted to meet individual athlete needs.
Professional qualifications/experience should be considered prior to de-
signing and implementing interventions (Danish, Petitpas, & Hale, 1992;
Heil, 1993). Sport psychology consultants need to clarify their role, iden-
tity, and qualifications across various settings and athlete populations. For
example, Brewer et al. (1991) suggested four roles for sport psychologists
120 CUPAL

working in medical settings: assessment, facilitating communication,

teaching psychological skills, and facilitating social support.
SUMMARY AND CONCLUSION
Findings from the 17 psychological intervention studies reviewed in
this article serve to stimulate further inquiry into the prevention and re-
habilitation of sport injury. These studies have enhanced understanding
of the interrelationships among psychological, psychosocial, and psycho-
biological variables through implementation of scientifically sound de-
signs and thoughtful application of multivariate statistical techniques. In-
jury prevention and rehabilitation interventions have successfully begun
to serve as adjuncts to performance or physical rehabilitation programs.
In spite of some methodological flaws, these interventions have demon-
strated positive outcomes, resulting in reduced injuries andor improved
physical and psychological outcomes. No one prevention or treatment
modality emerges as more effective than another; in general, investigators
have demonstrated efficacy with a variety of brief therapies that are pred-
icated on cognitive appraisal models. This small body of research pro-
vides a strong foundation for further development, implementation, and
evaluation of psychological interventions for sport injury prevention and
rehabilitation.

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Manuscript submitted: February 12, 1997