The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: https://www.tandfonline.com/loi/ipsm20

Psychosocial Interventions Help Facilitate

Recovery Following Musculoskeletal Sports
Injuries: A Systematic Review

Sonora M. Gennarelli, Symone M. Brown & Mary K. Mulcahey

To cite this article: Sonora M. Gennarelli, Symone M. Brown & Mary K. Mulcahey (2020):
Psychosocial Interventions Help Facilitate Recovery Following Musculoskeletal Sports Injuries: A
Systematic Review, The Physician and Sportsmedicine, DOI: 10.1080/00913847.2020.1744486

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 Publisher: Taylor & Francis & Informa UK Limited, trading as Taylor & Francis Group

Journal: The Physician and Sportsmedicine

DOI: 10.1080/00913847.2020.1744486
Psychosocial Interventions Help Facilitate Recovery Following Musculoskeletal

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Sports Injuries: A Systematic Review

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Sonora M. Gennarelli, BS1, Symone M. Brown, MPH2, Mary K. Mulcahey, MD2

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Tulane University School of Medicine
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Department of Orthopaedic Surgery, Tulane University School of Medicine
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Corresponding Author:

Mary K. Mulcahey, MD
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1430 Tulane Avenue, #8632

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New Orleans, LA 70112

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Phone: 504-988-3516

Email: [email protected]

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 Psychosocial Interventions Help Facilitate Recovery Following Musculoskeletal

Sports Injuries: A Systematic Review

Abstract

Context: Recent research demonstrates a connection between psychological factors and

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return to play following a musculoskeletal sports injury. Although it has been shown that

psychological factors can influence when and if an athlete returns to play, it is unclear if

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the implementation of psychosocial interventions during the recovery process can address

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these factors and potentially increase the likelihood of return to play after physical

recovery from injury.

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Objective: To examine the efficacy of interventions designed to address psychosocial
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factors that influence return to play after sports injuries.

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Methods: A systematic review was performed in accordance with the Preferred

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Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

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Pubmed, Embase, and Google Scholar databases were searched from the earliest entry

through May 2018. Search terms included “psychology,” “sports injury,” “anterior
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cruciate ligament injury,” “anterior cruciate ligament reconstruction,” “intervention,”

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“return to play,” and “return to sport.” Studies were included and reviewed if they

reported on the efficacy of a psychosocial intervention program in injured athletes.

Results: Initial searches of Pubmed, Embase, and Google Scholar databases identified

560 articles, 329 articles, and 34,400 hits, respectively. After inclusion and exclusion

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 criteria were applied, 8 articles remained that met inclusion criteria. Interventions of

relaxation/guided imagery, positive self-talk, goal setting, counseling, emotional/written

disclosure, and modeling videos were found to be effective interventions for promoting

recovery after musculoskeletal sports injury. These interventions facilitated positive

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mood changes, pain management, exercise compliance, and rehabilitation adherence. No

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study examined the effect of psychosocial interventions on return to play.

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Conclusion: This systematic review demonstrates that psychosocial interventions can

facilitate post-injury recovery in athletes by promoting a positive emotional state and

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rehabilitation adherence. Further research is necessary to determine the most effective
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psychosocial interventions for specific psychological factors, the ideal duration of

interventions, the best method of implementation following sports injury, and the impact
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of these interventions on return to play.

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Key terms: Sports injury, psychologic intervention, recovery, return to play

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Introduction

Physical performance tests (PPTs) that evaluate sport specific skills along with an
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assessment of pain, range of motion, and strength have been traditionally used to assess
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recovery from injury and readiness to return to play (RTP) [1,2]. Despite having achieved

adequate physical recovery, many athletes do not RTP or do not return at the same level

as they were playing prior to the injury [3]. This implies that there are multiple factors

that influence readiness to RTP.

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 Self-determination theory has been proposed as being important for RTP after a serious

injury [4,5]. This theory states that self-motivation and healthy psychological

development are related to three psychological needs being fulfilled: autonomy,

competence and confidence relating to one’s athletic abilities, and relatedness (perception

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of belonging in a social context). Positive psychological factors of motivation,

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confidence, and low fear have been previously associated with a greater likelihood of

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RTP [4].

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Recent research has supported the important connection between psychological factors

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and readiness to RTP after injury [3,4]. Kinesiophobia and fear of re-injury are reported
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to be two of the most important psychological factors that impact an athlete’s ability to

return to pre-injury activity level [6-11]. Studies have also found that negative
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psychological responses to injury such as anxiety, low self-esteem, and depression

negatively affect RTP [3,12]. Conversely, psychological predictors of optimism,

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including high self-efficacy, self-motivation, and strong athletic identity are positively
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associated with improved post-operative outcomes and RTP [3,13]. Positive

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psychological response after injury, as measured by motivation, confidence, and low fear

has also been associated with a higher likelihood of returning to sport following injury
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[4].
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Addressing the psychological factors that influence RTP with psychological

interventions, treatments based on a theory of psychological function, or more broadly

with psychosocial interventions, which encompass anything designed to improve mental

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 health (e.g. support, advice, and encouragement) during post-injury treatment may

improve outcomes and RTP. Previous studies on this topic have focused heavily on ACL

injuries, but some have also examined ankle, foot, and shoulder injuries. The purpose of

this systematic review was to examine the effectiveness of interventions aimed at

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addressing the psychosocial factors that can influence RTP after all sports injuries with a

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focus on ACL injuries since there is an abundance of research on the association of

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psychological factors and outcomes following that injury in particular.

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Methods

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A systematic review was performed according to the 2009 Preferred Reporting Items for
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Systematic reviews and Meta-Analyses (PRISMA) guidelines [14]. Pubmed, Embase,

and Google Scholar were searched for articles published from the database’s inception
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through May 2018. Upon initial literature review, it was found that the predominant

injury studied was ACL injuries. Therefore, in order to maximize the amount of papers
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returned with the search terms according to database indexing, the more broad terms of
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“sport injury,” and “sports injury,” were queried along with the addition of “anterior
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cruciate ligament injury,” and “anterior cruciate ligament reconstruction” for injury

terms. The keywords: “psychology,” “intervention,” “return to play,” and “return to

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sport” were the other search terms used with relevant analogous terms/synonyms
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connected by the Boolean AND operator and concept groups connected by the OR

operator to form the Pubmed search strategy. These terms were matched to MeSH terms

when possible while searching the Pubmed database. The same key words were used to

search Google Scholar. According to previously established convention, the first 100

search results obtained from the Google Scholar literature search were reviewed in this

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 study [15]. A similar strategy was utilized for mapping search terms in the Embase

database with keywords of “sport injury,” “anterior cruciate ligament injury,” “anterior

cruciate ligament reconstruction,” “psychological aspect,” “postoperative care,” “post

operative pain,” and “psychotherapy”. The Embase search results were further narrowed

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down to articles appearing only in Embase and articles published in English.

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Inclusion criteria consisted of: (1) English language, (2) patients who suffered an

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orthopaedic musculoskeletal sports injury, (3) at least one psychological or psychosocial

change was measured and reported, and (4) a psychosocial intervention was tested.

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Exclusion criteria were: (1) studies that focused on concussion injuries or other non-
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musculoskeletal injuries, (2) studies that did not examine post-injury psychosocial

interventions, (3) published psychological scale evaluations (4) papers that were not
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written in English (5) surveys regarding opinions about the injury experience and fear of

re-injury from athletes, medical practitioners, and therapists, that did not include an
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intervention and (6) review articles. The following information was extracted from the
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studies included in the systematic review: study population including age, patient sex,
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sports played, study design, psychosocial intervention tested, statistical data supporting

the intervention, and recovery/return to play data if provided.

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Results

Search Results

Initial search of Pubmed, Embase, and Google Scholar databases returned 560 Pubmed

articles, 329 Embase articles, and 34,400 Google scholar hits, from which the first 100

were screened. From the original 989 studies obtained from the database searches, titles

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 were screened and 872 studies were omitted based on exclusion criteria. An additional

101 papers were omitted after abstract review, leaving a total of 16 studies for full text

review. Eight papers were then excluded because they were review articles, leaving 8

papers for inclusion in the systematic review (Figure 1).

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Type of Interventions

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There were a variety of interventions described, including relaxation / guided imagery

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[16-18], positive self-talk [19] , goal setting [16,19,20], counseling [21],

emotional/written disclosure [22], and modeling videos [23]. All of these were found to

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be effective in promoting recovery by elevating mood, reducing anxiety, improving joint
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function, or improving effort and rehabilitation exercise completion after musculoskeletal

sports injury (Tables 1 and 2).

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Relaxation / Guided Imagery

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Relaxation combined with guided imagery has been found to be an effective psychosocial
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intervention after athletic injury. In 2000, Johnson et al. [16] evaluated the efficacy of
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incorporating psychosocial interventions (including relaxation and guided imagery)

during rehabilitation for 58 long-term injured athletes (minimum of 5 weeks out of

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training or competing) that competed at the national or international level. Numerous

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injuries were described, including (from most to least common) knee injuries, foot/ankle

injuries, and shoulder injuries. Every 4th patient was assigned to the intervention group,

which consisted of skills training in stress management, cognitive control, goal setting

skills, relaxation, and guided imagery. After assignment of every fourth patient to the

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 intervention group, the intervention group was comprised of 14 men and no women.

The relaxation and imagery training involved breathing techniques and imagining healing

and perfect function in the injured body part. The athletes in the intervention group were

told to practice for 15 minutes per day at least 4 times a week for the duration of their

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recovery. The authors found that the interventions had an overall mood elevating effect

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during and after the rehabilitation period. Relaxation and guided imagery when evaluated

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independently of other interventions led to a statistically significant improvement in

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mood elevation in the intervention group at the end of rehabilitation as compared to the

beginning of the intervention (f = 4.99, p=.008) as measured by the Mood Adjective

Checklist (MACL)[24] score.

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Cupal and Brewer [17] evaluated thirty patients that were recreational and competitive
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athletes during rehabilitation following anterior cruciate ligament (ACL) reconstruction.

Participants were randomly assigned to treatment, control (normal physical therapy

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without encouragement or support from the clinician), and placebo (standard physical
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therapy along with encouragement and support from the clinician) groups. Two weeks
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after surgery, baseline scale assessments on a scale of 1-10 for re-injury anxiety and pain

were completed. The intervention group received 10 sessions of relaxation and imagery
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at 2-week intervals over a 6-month period. At 24 weeks, the intervention group was
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found to have significantly lower pain (treatment p < .05, treatment adjusted M= 0.54,

placebo adjusted M = 2.80, control adjusted M = 3.44) and re-injury anxiety (treatment p

< .05, placebo adjusted M = 3.98, control adjusted M = 3.44). Additionally, the

intervention group demonstrated a significantly greater knee strength group mean

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 (M=0.83 p < .05), as compared to the control (M=0.66, p < .02) and placebo groups (M=

0.63, p < .003).

In 2012, Maddison et al. [18] evaluated the efficacy of a guided imagery and relaxation

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intervention for 21 male athletes after undergoing ACL reconstruction. The imagery and

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relaxation program described by Cupal and Brewer [17] was implemented in 9 sessions

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over a 6 month period along with standard post-operative rehabilitation. Six months after

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surgery, the authors measured strength, knee laxity, catecholamine and dopamine levels,

and self-efficacy. A statistically significant difference favoring the intervention group as

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compared to the control group (standard rehabilitation) was found for knee laxity (f=
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4.67, p < .05) with a larger improvement in knee laxity score in the intervention group as

measured pre- and post- intervention. Additionally, there was a statistically significant
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decrease in the level of noradrenaline (f (1,19) 19.65, p < .001) and dopamine (f (1,19)

6.23, p = .02) in the intervention group as compared to the control group, indicating
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lower levels of stress in the intervention group. No differences were found for knee
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strength at 180°/s (p = 0.67) and 60°/s (p = 0.48). Additionally, self-efficacy (belief in

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their own ability to complete their rehabilitation program and return to full function) was

similar between control and intervention groups and showed a decrease in both over the
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course of the study.

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Positive Self-talk and Cognitive Restructuring

Positive self-talk, or self- encouragement, is helpful in promoting the completion of

rehabilitation exercises. In 2001, Scherzer et al. [19] performed a study using abbreviated

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 subscales of the Sports Injury Survey [25] in which they evaluated 54 patients five weeks

after undergoing ACL reconstruction. Patient scores on the survey were compared with

their rehabilitation adherence, which was measured at each outpatient physical therapy

appointment through tracked attendance, rehabilitation practitioner completion of the

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Sport Injury Rehabilitation Adherence Scale [26], and having study participants rate their

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level of home exercise completion for the week on a scale of 1 to 10. The authors found a

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significant positive correlation between positive self-talk and completion of home

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exercises (r =. 52, p < .05). There were no significant correlations between positive self-

talk and rehabilitation appointment attendance (r = -.21, p > .05).

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Goal Setting

Setting short- and long-term goals for rehabilitation and for eventual RTP is important for
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maintaining motivation throughout the rehab process. In 2001, Scherzer et al. [19], tested

goal setting as an intervention to improve rehabilitation adherence after ACL

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reconstruction. Through surveys and tracked attendance at rehabilitation sessions, the

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authors found a positive correlation between goal setting and higher rates of exercise
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compliance at home (beta = .51, p < .005) as well as effort during rehabilitation

appointments (beta = .35, p < .05) in athletes recovering from ACL reconstruction, as
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rated by rehabilitation practitioners on the Sport Injury Rehabilitation Adherence Scale

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[26]. The previously mentioned study by Johnson et al. [16] also tested goal setting as a

short-term intervention along with relaxation/guided imagery, and stress management.

Goal-setting skills training was implemented to teach the athletes how to set long-term,

intermediate, and daily goals for their rehabilitation training. Pre-treatment and post-

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 treatment measurements were made with the Mood Adjective Checklist [24]. The authors

found that goal setting elevated the mood of the injured athletes both during and at the

end of the prescribed physical rehabilitation, but was not found to be statistically

significant. Similarly, Evans et al. [20] performed a goal setting intervention on 39

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injured that had surgery on the knee. Participants were randomly assigned to the

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intervention group, a control group (standard physical therapy), or a social support group.

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The intervention group met with a sports psychologist for 60 to 105 minutes every 7 to 10

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days for 5 weeks, during which time they reevaluated goals together. The social support

group also met with the sport psychologist for 40 to 60 minutes every 7 to 10 days for 5

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weeks, but the sport psychologist simply listened and provided emotional support rather
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than offering an intervention. The authors found that athletes in the goal setting

intervention group had much higher self-reported adherence to their rehabilitation

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program with a statistically difference between the intervention group (M of 78.83), the

social support group (M of 51.84), and the control group (M of 49.09) (p < .008). They
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also had significantly higher levels of self-efficacy than the control group but not the
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social support group with an intervention group mean of 24.64, social support group
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mean of 23.88, and a control group mean of 20.46 (p < .008).

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Counseling
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Previous studies have demonstrated the efficacy of counseling in increasing rehabilitation

adherence. Rock and Jones [21] implemented a counseling intervention for 3 athletes

recovering from ACL reconstruction. None of the athletes had previously identified

psychological factors. Counseling sessions of 40-60 minutes, in which the counselor

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 acted as a source of listening and social support for the injured athlete and helped them

cope with negative feelings, were implemented 3 days after surgery and then again at 2-

week intervals through the 10th week after surgery. The authors found that counseling

promoted rehabilitation adherence when examining each athlete over time as measured

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by the Sport Injury Rehabilitation Adherence Scale [26].

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Emotional written disclosure

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Athletes commonly experience loss of athletic identity during injury and ensuing grief

related feelings of depression, anxiety, and feeling cheated after injury. Emotional written

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disclosure, or interventions that encourage patients to write down their feelings about the
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injury, have been shown to be helpful in counteracting the grief-related negative

emotions that are common in long-term post-injury recovery and can potentially
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influence the athlete’s RTP. Mankad et al. [22] performed a study on a random sample of

9 injured athletes who were were 3-4 months post-surgery. The intervention consisted of
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writing down negative feelings and emotions related to long-term injury for 20 minutes a
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day for 3 consecutive days. The athletes’ psychological response pre-intervention and
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post-intervention were measured using the Psychological Responses to Sport Injury

Inventory [27]. The intervention was found to reduce athletes’ grief-related responses (f
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(2,16) = 5.15, p = .019) and increase self-reported motivation and acceptance of injuries
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as compared to the baseline measured in the athletes before the intervention.

Modeling

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 Maddison et al. [23] performed a randomized control study on 58 athletes that had

undergone ACL reconstruction. Coping modeling videos (models performing the

rehabilitation exercises and discussing difficulties faced during rehabilitation and how to

overcome them) were used as a post-operative intervention. The intervention included

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watching a 9-minute modeling video twice (both pre- and post-operatively) before

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hospital discharge focusing on the first two weeks of rehabilitation. The videos covered

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early recovery exercises to promote flexion, extension, and walking both with and

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without crutches. Participants also watched a different 7-minute modeling video, once at

week 2 and again at week 6 of rehabilitation that reviewed the exercises completed in

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those phases of rehabilitation. Each modeling video intervention was followed by the
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completion of psychological questionnaires that involved rating expected pain on a scale

of 0 (no pain) to 100 (worst possible pain), completing the State Trait Anxiety Inventory
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(STAI) [28] and rehabilitation self-efficacy (confidence) scales [29]. The authors found

the intervention reduced perceptions of expected pain preoperatively (f (1,56) = 5.42, p <
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.05) and improved self-efficacy (t (56)=2.27, p <. 05, d=.47) during rehabilitation
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exercises immediately following surgery in those that watched the videos as compared to
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the control group. The patients in the modeling group needed crutches for significantly

less time (f (2,56) = 19.65, p <. 01, d = .94) with an intervention group mean of 5.54 days
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and control group mean of 9.34 days. The modeling group also had better scores on
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International Knee Documentation Committee (IKDC) assessments (f (2,55) = 3.01, p =

.01) with an intervention group mean score of 61.18 and control group mean score of

57.02, showing less functional disability in the intervention group compared to the

control group at 6 weeks.

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 Outcomes

Although all of the papers included in this systematic review evaluated whether the

intervention tested was beneficial to recovery after injury (or post-operatively), none

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specifically examined RTP as an outcome measure. Instead, they examined efficacy of

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the intervention in promoting recovery by increasing positive mood changes [16] and

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rehabilitation adherence [19,20]. The studies also evaluated the efficacy of the

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interventions with regards to reducing negative emotional states (e.g. stress and anxiety)

[17,21,22], improving pain management [17,23], and increasing exercise compliance [19]

in the post-injury recovery period.

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Discussion
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The primary finding of this systematic review was that psychosocial interventions are

effective at promoting the recovery process when used during rehabilitation after
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musculoskeletal sports injuries. This systematic review focused on ACL injuries because
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there is an abundance of research on the association of psychological factors and outcome

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following that injury in particular. More research is needed concerning ankle, shoulder,

and foot injuries; however, the association of psychological factors and outcomes
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following these injuries were included where possible. Relaxation and guided imagery
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were found to improve pain management, increase self-efficacy, manage stress, and

reduce re-injury anxiety in athletes with knee, foot/ankle, and shoulder injuries [16-18].

Positive self-talk and cognitive restructuring were helpful in dealing with post-injury

negative mood disturbances and lead to increased rehabilitation adherence and feelings of

positive rehabilitation self-efficacy in patients recovering from ACL reconstruction

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 [3,30]. Goal setting was also associated with increased motivation, exercise compliance,

and rehabilitation awareness along with increasing positive feelings of self-efficacy in

athletes that participated in a wide variety of sports and had injuries to the knee,

foot/ankle, or the shoulder [19,20]. Counseling provided a source of emotional and social

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support, thereby positively influencing rehabilitation program adherence in athletes

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recovering from ACL reconstruction [21]. Emotional/written disclosure improved

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acceptance of injury, reduced grief-related responses, increased motivation, and

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perceived sense of control in the recovery process and was found to be effective for

reducing stress and negative mood disturbances in athletes recovering from ACL

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reconstruction, PCL reconstruction, or a neck injury [22]. Finally, modeling videos were
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shown to reduce pain and anxiety along with increasing athletic confidence and feelings

of self-efficacy in a group following ACL reconstruction.

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Psychological factors and mood state have shown to be important and predictive of an
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athlete’s ability to RTP following a musculoskeletal injury. Previous research has

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established that negative psychological responses to injury (e.g. anxiety, low self-esteem,
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and depression) adversely affect RTP and are negatively predictive of returning to sports

[3,12]. Conversely, positive self-efficacy and strong athletic identity (associated with
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increased rehabilitation adherence in younger athletes) have shown to be prognostic of

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improved post-operative outcomes and eventual RTP after musculoskeletal injuries

[3,13]. Motivation, confidence, and low fear of re-injury have also been associated with a

higher likelihood of RTP following injury [4]. Since the psychosocial interventions

discussed in this review may help promote positive psychological factors (e.g. self-

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 efficacy, confidence, and athletic identity), while also reducing negative factors (e.g.

anxiety and depression), they may not only be important to the rehabilitation and

recovery process, but may also influence the ability of an injured athlete to RTP.

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Limitations

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There are several limitations to this study. First, all of the interventions described in the

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studies were only performed at a single time point. No follow up study was done to see

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results over time. Second, many of the studies included male and female athletes in

different sports and varying ages, but most of the studies only examined athletes

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recovering from ACL reconstruction, therefore the results may not be generalizable to
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athletes recovering from other injuries. Third, many of the studies used surveys or

questionnaires to assess the efficacy of the intervention; however, a detailed analysis

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(including evaluating for clinical significance) was rarely performed. This information is

necessary to determine the therapeutic value of the interventions. Fourth, only three
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databases were reviewed. It is possible that other relevant articles would have been
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identified if more databases were included. Fifth, no official quality assessment was done
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on the studies reviewed. Finally, none of the studies measured effect on return to play.

Further studies are necessary to address this question.

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Conclusion

There is evidence that psychosocial interventions facilitate post-injury recovery in

athletes. Relaxation, guided imagery, positive self-talk, goal setting, counseling,

emotional/written disclosure, and modeling videos were found to be effective in

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 promoting recovery after musculoskeletal sports injuries. All techniques reduced negative

emotions and increased rehabilitation adherence and feelings of self-efficacy. Future

research regarding the use of psychosocial interventions in athletes following

musculoskeletal injury and the effect on RTP is warranted.

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23. Maddison R, Prapavessis H, Clatworthy M. Modeling and rehabilitation following

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anterior cruciate ligament reconstruction. Ann Behav Med. 2006 Feb;31(1):89-98.

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24. Sjöberg L, Svensson E, Persson LO. The measurement of mood. Scand J Psychol.

1979;20(1):1-18.

25. Ievleva L, Orlick T. Mental links to enhanced healing: An exploratory study. The

Sport Psychologist. 1991;5(1):25-40.

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 26. Brewer BW, Van Raalte JL, Petitpas AJ, et al. Preliminary psychometric

evaluation of a measure of adherence to clinic-based sport injury rehabilitation.

Physical Therapy in Sport. 2000;1(3):68-74.

27. Evans L, Hardy L, Mullen R. The development of the psychological responses to

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sport injury inventory. J Sport Exerc Sci. 1996;14:27-28.

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28. Spielberg C, Gorsuch R, Lushene R, et al. Manual for the state-trait anxiety

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inventory. Palo Alto. CA: Consulting psychologists press; 1970.

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29. McAuley E MS. Measuring exercise related self-efficacy. Morgantown, WV:

Fitness Information Technology; 1998. (JL ID, editor. Advances in Sport and

Exercise Psychology Measurement.).

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AN
30. Nippert AH, Smith AM. Psychologic stress related to injury and impact on sport

performance. Phys Med Rehabil Clin N Am. 2008;19(2):399-418.

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 Records identified through
database searching: (n = 989)
Pubmed (n=560), Google Scholar
(n=100), Embase (n=329)

Records excluded,
with reasons: (n =872)
Duplicates (2)

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Records screened by title Not in English (1)
(n =989) Non-musculoskeletal injuries

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(76)
Scale validation (20)

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Views on injury/fear (15)
No psychological intervention

SC
(751)
Case study (1)
Records screened by abstract
Book (4)
(n=117)

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Records excluded,
with reasons: (n =101)
No psychological intervention
(101)
Full-text articles assessed for
M

Surveys on fear of re-injury

eligibility
(n =16)
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Records excluded,
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With reasons: (n =8)

Reviews (8)
Articles included after full text
review
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(n=8)
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Figure 1: PRISMA flow diagram summarizing the literature search

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Table 1: Psychological intervention data

Author Injury Sustained Sport Demographics Intervention Intervention Psychosocial Clinical Outcome
or Surgery Time/Duration Factor Measurement
Addressed

Johnson et al. • Knee injuries • Football (33) • 52 men, 6 Relaxation / • 15 min per day (at Depression • Mood • Mood elevation
[16] • Foot/ankle • American women Guided least 4 times a Adjective (f=4.99, p=.008)
injuries football (4) • Mean age of imagery week) Checklist
• Shoulder injuries • Handball (8) 23.7 (SD = • Duration of injury (MACL) [24]

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• Floor ball (3) 4.3) recovery
• Volleyball (1)

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• Table tennis
(2)
• Gymnastics

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(2)
• Track and
field (2)

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• Other (3)

Cupal and • ACL • Downhill • 16 men, 14 Relaxation / • 10 sessions at 2 Re-injury • Re-injury • Pain reduction
Brewer [17] reconstruction skiing (14) women (7 Guided week intervals anxiety anxiety and (p<.05)
• Basketball (8) competitive imagery • 2 weeks after pain scales (on • Reduced re-
• Soccer (2) collegiate surgery to 24 scale of 1 to injury anxiety
• Hockey (1)
• Volleyball (1)
athletes)
• Mean age of
U weeks 10) (p<.05)
• Greater knee
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• Rodeo (1) 28.2 with a strength (p<.05)
• Other (3) range of 18-
50 years
Maddison et • ACL Not provided • 21 men Relaxation / • 9 sessions over a 6 Stress reduction • Strength, • Improved knee
al. [18] reconstruction • Mean age of Guided month period • Knee laxity laxity
imagery (f=4.67, p<.05)
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34.9 (SD = • Catecholamine

8.8) levels • Noradrenaline
• Dopamine (f (1,19) 19.65,
levels p < .001)
• Self-efficacy • Dopamine
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(f (1,19) 6.23,
p = .02)
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Scherzer et • ACL Not provided • 37 men, 17 Positive self • 5 weeks after Motivation • Sports Injury • Improved
al. [19] reconstruction women talk / surgery through Survey [25] completion of
• Mean age of Cognitive remainder of • Sport Injury rehabilitation
28 (SD = 8.3) restructuring physical Rehabilitation exercises at
rehabilitation Adherence home
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period at each Scale [26] (r=.52, p<.05)

appointment
Scherzer et • ACL Not provided • 37 men, 17 Goal setting • 5 weeks after Motivation • Sports Injury • Positive
al. [19] reconstruction women surgery through Survey [25] association with
• Mean age of remainder of • Sport Injury higher effort
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28 (SD = 8.3) physical Rehabilitation (beta = .35,

rehabilitation Adherence p < .05) and
period at each Scale [26] higher rates of
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appointment exercise
compliance at
home
(beta = .51,
p < .005)

Johnson et al. • Knee injuries • Soccer (33) • 52 men, 6 Goal setting • 15 min per day (at Depression • Mood • Mood elevation
[16] • Foot/ankle • Football (4) women least 4 times a Adjective during and after
injuries • Handball (8) • Mean age of week) Checklist prescribed
• Shoulder injuries • Floor ball (3) 23.7 (SD = • Duration of injury (MACL)[24] physical
• Volleyball (1) 3.4) recovery rehabilitation
• Table tennis period
(2)

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 • Gymnastics
(2)
• Track and
field (2)
• Other (3)

Evans et al. • ACL or PCL Not provided • 33 men, 6 Goal setting • 60 to 105 minutes Motivation / • Higher self- • Higher self-
[20] surgery (30) women every 7 to 10 days Self efficacy reported reported
• Shoulder • Mean age of • 5 weeks period adherence adherence to
dislocation 25.4 years • Higher self- rehabilitation
surgery (6) with a range reported self- program
• Lower leg of 17-39 efficacy (p <.008) and

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fracture (3) years higher levels of
self-efficacy

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(p <.008)

Rock and • ACL • Football (2) • 2 men, 1 Counseling • 40-60 minutes Depression / • Sport Injury • Promotes
Jones [21] reconstruction • Badminton woman • 2 week intervals Anger Rehabilitation rehabilitation

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(1) • Mean age of for 10 weeks Adherence adherence over
35.3 with a following surgery Scale [26] time
range of 31- • Helps cope with

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40 years negative feelings

Mankad et • ACL • Soccer • 4 men, 5 Emotional • 20 minutes a day Motivation and • Psychological • Reduce grief-
al. [22] reconstruction • Rugby women written for 3 consecutive depression Responses to related responses
(7) • Basketball • Mean age of disclosure days Sport Injury (f (2,16) = 5.15,
• PCL
reconstruction
(1)
22.2 years
(SD of 4.2)
U • 3-4 months post
surgery
Inventory [27] p = .019)
• Increase
motivation and
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• Neck ligament injury
surgery (1) acceptance

Maddison et • ACL • Rugby (32%) • 58 athletes Modeling • Watching Anxiety, self- • Rating • Reduced
al. [23] reconstruction • Soccer (18%) (68% male, modeling video 1 efficacy, expected pain anxiety,
confidence
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• Snow sports 32% female) pre and post on a scale of 0 perceptions of

(11%) • Age range of operatively (no pain) to expected pain
• Water sports 15-53 (covered first 2 100 (worst preoperatively
(5%) weeks of rehab) possible pain) (f (1,56) = 5.42,
• Netball (8%) • Watching video 2 • State Trait p < .05)
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• Other (26%) at week 2 of rehab Anxiety • Improved self

• Watching video 3 Inventory efficacy and
at week 6 of rehab (STAI) [28] confidence at
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• Rehabilitation pre-discharge
self-efficacy rehabilitation
(confidence) exercises
scales [29] (t (56)=2.27,
p <. 05, d=.47)
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• Less time on
crutches
(f (2,56) = 19.65,
p <. 01, d = .94)
• Better scores on
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International
Knee
Documentation
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Committee
(IKDC)
assessments
(f (2,55) = 3.01,
p = .01)

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 Table 2: Types of psychosocial interventions utilized
Intervention Author
Relaxation/Guided imagery • Johnson et al. [16]
• Cupal and Brewer [17]
• Maddison et al. [18]
Positive self talk/Cognitive restructuring • Scherzer et al. [19]
Goal setting • Johnson et al. [16]
• Scherzer et al. [19]

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• Evans et al. [20]

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Counseling • Rock and Jones [21]
Emotional written disclosure • Mankad et al. [22]
Modeling • Maddison et al. [23]

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SC
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TE
EP
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