Psychology of Sport Injury PDF

60 Psychology of Sport Injury on her rehabilitation program—she withdrew once again as the reality hit that she was going to miss her junior year of high school soccer and was unlikely to be anywhere near her best for the all-important spring club season. Having yet to make a college commitment, D...

60 Psychology of Sport Injury on her rehabilitation program—she withdrew once again as the reality hit that she was going to miss her junior year of high school soccer and was unlikely to be anywhere near her best for the all-important spring club season. Having yet to make a college commitment, Danielle saw her goals and dreams crashing in front of her and felt powerless to do anything about it. Nicole’s response to her injury bore little resemblance to Danielle’s. She experienced some pain for the first week or two after the injury but did not seem to be bothered by the physical limitations caused by the injury. In fact, her mental state seemed so normal that her parents felt concerned that something was wrong. Nicole reported feeling a sense of “lightness,” as if a heavy weight had been lifted off of her shoulders. She was, in her words, a “grump” after her surgery because of the challenges associated with getting around on crutches and the pain she experienced when she forgot to take her medication. But her grumpiness passed quickly, and she balanced her school and rehabilitation efforts with social activities that she had not previously had time to engage in due to her heavy soccer commitments. She knew that her chances of playing collegiate soccer at a top Division I school were essentially nil, but she was comfortable with that prospect and felt determined to make the most of what life had to offer in the days, weeks, and months ahead. Danielle and Nicole each experienced a severe physical injury that, in addition to the extensive physical consequences, can exact a psychological toll. However, despite sustaining essentially the same injury under similar circumstances, Danielle and Nicole reacted psychologically in ways that differed dramatically. Why, given their apparent similarities, did these two young athletes respond so differently to the challenges of injury? This chapter tackles that question and addresses cognitive, emotional, and behavioral responses to sport injury, as well as factors thought to influence those responses. First, however, it describes models of psychological response to sport injury and summarizes the available empirical support for those models. Models of Psychological Response to Sport Injury In order to provide athletes with the best psychological help in the wake of injury, we must understand the process of psychological adjustment to sport injury. Since the earliest published report (Little, 1966) indicating that at least some athletes might experience psychological difficulties after sustaining an injury, researchers have proposed models of psychological response to sport injury and evaluated those models scientifically. Early attempts, faced with an absence of relevant sci- entific data, borrowed heavily from other areas of psychology. Over time, two main types of psychological-adjustment models have been developed: stage models (inspired by the literature on grief reactions) and cognitive appraisal models (drawing on theory and research about stress and coping). Stage Models Two main assumptions underlie stage models of psychological adjustment to sport injury. The first assumption is that when athletes become injured, they lose part of themselves (Peretz, 1970). Given that athletes can derive a sense of identity and a social role from participating in sport (Brewer, Van Raalte, & Linder, 1993), they can experience a state of loss when injury deprives them of these benefits. The second assumption is that when athletes become injured, they follow a predictable, immutable sequence of psychological responses on the way to achieving satisfactory adjustment. In positing this sequence, several sport psychologists (e.g., Astle, 1986; Lynch, 1988; B. Rotella, 1985) adapted a popular model of adjustment to terminal illness (Kübler-Ross, 1969); specifically, they suggested that athletes progress sequentially through the stages of denial, anger, bargaining, and depression before reaching acceptance. Other sport-specific stage models have also been proposed, and they vary somewhat B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. Psychological Responses to Sport Injury   61 in the number, names, and content of stages (L. Evans & Hardy, 1995). Stage models carry enormous practical appeal (Rohe, 1988) because they imply that knowing the stages enables us to understand what an athlete has experienced and predict what lies ahead. Consistent with the tenets of most stage models, research has shown that some athletes do experience psychological responses akin to grief reactions after sustaining a serious injury (Macchi & Crossman, 1996). They also show a general trend in which an athlete’s psychological responses become more favorable over time (e.g., McDonald & Hardy, 1990; A.M. Smith, Scott, O'Fallon, & Young, 1990). These findings, however, are not uniquely supportive of stage models. Indeed, it is not necessary to invoke the concept of developmental stages in order to accept the idea that some athletes may feel quite distressed after sustaining an injury and that, with time, they are likely to show improved psychological functioning. In addition, in summarizing the criteria of explanatory stage models as defined by Piaget (1971), Rape, Bush, and Slavin (1992) noted that “stages must follow an invariant sequence such that (a) the sequence is culturally universal, (b) it occurs in the same order for everyone, (c) all individuals reach the last stage, and (d) there is never regression from a higher to a lower stage” (pp. 10–11). However, research has not supported the claim that athletes respond psychologically to injury by going through a stereotypic, invariant sequence of reactions (Brewer, 1994). Instead, as shown later in this chapter, athletes vary extensively in terms of how they respond to injury; in other words, no uniform pattern of response to injury has been documented. Athletes may experience responses aligned with some of the stages but not with others, and they may do so in an order that differs from those proposed in stage models (Tracey, 2003). Exhaustive reviews of research on adjustment to other threatening events, including terminal illness, have also reached the conclusion that the assumptions of stage models are not tenable (Silver & Wortman, 1980; Wortman & Silver, 1987; see also the cogent analysis by R. Friedman & James, 2008). To illustrate the difficulties of applying stage models to the full range of circumstances surrounding sport injury, consider that these models make no distinction between a relatively minor injury that keeps an athlete out of action for a few weeks and a severe injury that signals the end of an athlete’s competitive career. According to stage models, both injuries would be expected to trigger the same set of adjustment stages even though the degree of loss differs dramatically. Nor do stage models account for differences in athletes’ circumstances. This rigidity has made it difficult for stage models to establish a scientific foundation. It is possible to recognize the potential relevance of the grief response to sport injury while still rejecting the notion that athletes follow a universal pattern of psychological response to sport injury (L. Evans & Hardy, 1995, 1999). If we uncritically accept the existence of adjustment stages following sport injury, we run the risk of assuming that athletes are or will be distressed following injury and that athletes who experience emotional disturbance following injury will inevitably achieve resolution or acceptance if left alone. In reality, postinjury psychological distress should be neither expected nor dismissed (Brewer, 1994), lest the stages become “iron-plated pigeonholes into which human experience must somehow be made to fit" (Hopson, 1981, p. 37) or lest we fail to recognize and respond to an athlete’s experience of distress. Cognitive Appraisal Models Whereas stage models were not designed to account for individual differences in psychological response to sport injury, cognitive appraisal models were explicitly intended to fulfill that very function. Instead of expecting all athletes to respond to injury in a predictable way, cognitive appraisal models posit that athletes’ appraisals or interpretations of their injuries—along with the contexts in which they occur—play central roles in determining how athletes respond cognitively, emotionally, and behaviorally. B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. 62 Psychology of Sport Injury One example can be found in the integrated model of psychological response to sport injury (Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998), which evolved over several iterations and is displayed in figure 4.1. This model views sport injury as a stressor that initiates a process in which athletes appraise both the nature of the injury and their ability to cope with it. Cognitive appraisals are thought to be influenced by numerous personal and situational factors, including the psychosocial factors posited in the stress–injury model as potential contributors to sport injury occurrence (i.e., personality, history of stressors, coping resources). Personal factors consist of dispositional and historical characteristics of the individual, whereas situational factors consist of characteristics of the physical, social, and sport environments. In turn, cognitive appraisals are thought to affect three primary, interrelated domains of psychological response to sport injury: cognitive, emotional, and behavioral. More generally, the process of psychological adjustment to sport injury is considered to be dynamic, reflecting the ongoing reciprocal influence of potentially ever-changing thoughts, feelings, and actions. Psychological responses are also thought to affect psychosocial and physical recovery outcomes (these associations are discussed in detail in chapter 7). In the predictions of stage models, predictions generated by cognitive appraisal models have received abundant research support. For example, evidence has been obtained that • athletes find injury to be a significant source of stress (Bianco, Malo, & Orlick, 1999; Brewer & Petrie, 1995; L. Evans, Wadey, Hanton, & Mitchell, 2012; Ford & Gordon, 1999; Gould, Udry, Bridges, & Beck, 1997a; Heniff, 1998); • various personal and situational factors are related to psychological responses to sport injury (for a review, see Brewer, 2007); and • psychological responses are associated with sport injury rehabilitation outcomes (for a review, see Brewer, 2010). Also in contrast to the stage approach, the cognitive appraisal framework is marked by inher- ent flexibility and inclusiveness that allow the model to consider a multitude of possible predictors of psychological adjustment. Psychological Consequences of Sport Injury As illustrated by the cases of Danielle and Nicole, presented at the beginning of this chapter, sport injury can exert a dramatic effect not only on physical functioning but also on psychological functioning. Although investigating the psychological consequences of sport injury has presented researchers with a unique set of challenges (for more information, see this chapter’s Focus on Research box), a sizable body of empirical literature has accumulated over the past three decades. The following sections examine cognitive, emotional, and behavioral responses to sport injury; where relevant, they also identify personal and situational predictors of those responses. Cognitive Responses to Sport Injury Beginning with cognitive appraisals of the injury and proceeding through rehabilitation into the return to sport, cognition is a vital and omnipresent part of the process. The following aspects of cognition are especially involved in the psychological response to sport injury: • • • • • • • • Cognitive appraisals Attributions for injury Cognitive content Self-related cognition Cognitive coping strategies Perceived benefits of injury Injury-related perceptions Cognitive performance Cognitive Appraisals As noted earlier, injury-related cognitive appraisals initiate the process by which athletes respond psychologically to injury. Stress and coping theory (Lazarus & Folkman, 1984) suggests that the way in which people interpret (or B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. Psychological Responses to Sport Injury   63 Preinjury Personality Stress response History of stressors Personal factors Sport injury Response to sport injury and rehabilitation process • Injury • Demographic • History • Gender • Age • Severity • Ethnicity • Type • Perceived cause • Socioeconomic • Recovery status status • Individual differences • Prior sport experience • Psychological • Physical • Personality • Self-perceptions • Use of • Self-motivation ergogenic aids • Physical • Motivational health status orientation • Disordered • Pain tolerance • Athletic identity eating • Coping skills • Psychological skills Behavioral response • History of • Adherence to stressors rehabilitation • Mood states • Use of PST strategies • Use or disuse of social support • Risk taking behaviors • Effort and intensity • Malingering • Behavioral coping Cognitive appraisal • Goal adjustment • Rate of perceived recovery • Self-perceptions • Belief and attributions • Sense of loss or relief • Cognitive coping Recovery outcomes • Psychosocial • Physical Factors Coping recources Interventions Situational factors • Sport • Type • Level of competition • Time in season • Playing status • Practice vs. game • Scholarship status • Social • Teammate influences • Coach influences • Family dynamics • Sports medicine team influences • Social support provision • Sport ethic or philosophy • Environmental • Rehabilitation environment • Accessibility to rehabilitation Emotional response • Fear of unknown • Tension, anger, depression • Frustration, boredom • Positive attitude or outlook • Grief • Emotional coping Figure 4.1 Integrated model of psychological response to sport injury. Wiese-Bjornstal et al. 1998. E5665/Brewer/F04.01/541520/MattH/kh-R4 appraise) an environmental event or situation determines their emotional and behavioral reactions to it. Three basic forms of cognitive appraisal are postulated: primary appraisal, secondary appraisal, and reappraisal. In primary appraisal, the environmental event or situation (e.g., a sport injury) is assessed in terms of its implicati`ons for the individual’s well-being. An event may be considered irrelevant (e.g., “the injury is unimportant”), benign-positive (e.g., “I needed a rest anyway”), or stressful (e.g., “the injury could not have come at a worse time”). Appraisals of an event or situation that is deemed stressful include interpretations of harm (or loss), threat, and challenge. Appraisals of threat and harm (or loss) are especially likely in the context of sport injury, which involves physical damage (Clement & ArvinenBarrow, 2013; Ford & Gordon, 1999; Gould et al., 1997a). Threat appraisals in particular involve anticipation of future harm, whereas challenge appraisals imply that the injury offers an opportunity for growth. Different kinds of appraisal are not necessarily mutually B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. Focus on Research Priorities, Pitfalls, and Pragmatics in Postinjury Psychological Research 64 Researching the psychology of sport injury is not for the weak of will. Studying the prediction and prevention of sport injury involves numerous challenges and potential frustrations. It requires researchers to gather psychological data and deliver psychological interventions to large numbers of athletes before they sustain an injury, then record athletes’ sport exposures on an ongoing basis, monitor their injury status, and collect pertinent injury and time-loss data. Conducting research on the psychological consequences of sport injury can be even more challenging. Consider first that the theoretically optimal method for examining the psychological effect of sport injury—experimentation—is neither ethical nor feasible (and even if it were, it might be difficult to recruit participants for a study in which they could be randomly assigned to the injury condition!). With experimentation off the table, prospective investigators face three major threats to the validity of their findings: Cognizant researchers design their studies to address these issues as best they can, given the specific questions for which they are seeking answers. Pragmatic concerns usually dictate that compromises be made on one or more of the issues. Athletes’ preinjury psychological characteristics are important because, as shown in chapter 2, psychological factors can cause or contribute to the occurrence of sport injury. Without assessing athletes’ preinjury psychological characteristics, we cannot determine whether their postinjury psychological characteristics are causes or consequences of sport injury. Similarly, we need to know the psychological characteristics of the sample from which an injured athlete is drawn, because the athlete’s postinjury psychological characteristics could be influenced by something in his or her sport experience other than the injury, and this influence (e.g., losing season, team disharmony) could be shared by teammates or coparticipants. Leddy, Lambert, and Ogles (1994) addressed these issues—that is, psychological characteristics of individual athletes before injury and of the sample from which injured athletes are drawn. They did so in a single study with a prospective research design in which a large sample of male collegiate athletes (n = 343) was assessed on measures of anger, depression, and selfesteem during the preseason. When athletes became injured, they (and a set of matched controls) completed exclusive (Lazarus & Folkman, 1984). For example, an athlete might simultaneously interpret an injury as causing harm or loss and as presenting a challenge. This response acknowledges the injury’s effect but views the rehabilitation process as a chance to apply personal resources toward recovery. In secondary appraisal, individuals assess what can be done to manage the stressful event; this type of appraisal takes into account both outcome expectancy and efficacy expectations (Lazarus & Folkman, 1984). Outcome expectancy involves the belief that a particular behavior will produce certain outcomes, whereas efficacy expectations involve the belief that one can perform the given behavior to bring about certain outcomes (Bandura, 1977, 1982). Thus, in secondary appraisal, the athlete considers what can be done about the injury, whether it can be treated, and whether he or she can do what is required to bring about recovery. The third basic form of cognitive appraisal is reappraisal, which involves modifying an appraisal based on new information (Lazarus & Folkman, 1984). For example, learning of an effective treatment technique might lead an athlete to change her or his appraisal of an injury’s effects. Reappraisal emphasizes the ongoing nature of the appraisal process; indeed, an athlete’s perceptions of an injury are subject to change throughout the rehabilitation period. Cognitive appraisals are influenced by a variety of personal and situational factors. With respect to sport injury, cognitive appraisals are • Athletes’ preinjury psychological characteristics • Psychological characteristics of the sample from which the injured athletes originate • Characteristics of the injuries experienced B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. the psychological measures within one week of injury and again two months later. The preinjury assessment controlled for the potential influence of preinjury psychological characteristics on postinjury psychological characteristics and on the postinjury assessments. The postinjury assessments controlled for any sample- or team-specific trends (independent of injury status) in the psychological characteristics that were measured. Unfortunately, studies as thorough and methodologically rigorous as this one are few and far between. The third potential threat to the validity of data collected on the psychological consequences of injury involves the characteristics of the injuries experienced. Psychological responses to sport injury may be greatly affected by the nature of the injury itself—for example, location, severity, duration, and symptoms. There is evidence, for example, that emotional responses of athletes who experience musculoskeletal injuries differ from those of athletes who sustain concussions (Hutchison, Comper, Mainwaring, Richards, & Bisschop, 2011; Mainwaring, Hutchison, Bisschop, Comper, & Richards, 2010). Even in carefully controlled studies, such as the one conducted by Leddy et al. (1994), the sample is typically heterogeneous with respect to the injuries experienced. One way in which researchers attempt to deal with this issue is to collect data from a group of athletes with a common injury after the injuries have occurred. Of course, taking such an approach results in a trade-off with respect to the first two threats to the validity of the postinjury data because it does not collect preinjury or peer-versus-control data. Researchers sometimes collect longitudinal psychological response data starting with the occurrence of the injury or an equalizing event, such as surgery, and use the individual athletes as their own controls. For example, multiple assessments of emotional functioning have been made following ACL reconstructive surgery in several studies (e.g., Brewer, Cornelius, et al., 2007; Langford, Webster, & Feller, 2009; Morrey, Stuart, Smith, & Wiese-Bjornstal, 1999). Even with imperfect studies that do not address most or even all of the three threats to the validity of self-reports, useful information can still be gleaned from the data. Of particular note, findings from case studies (e.g., Carson & Polman, 2008; McArdle, 2010), qualitative investigations (e.g., Bianco et al., 1999; Carson & Polman, 2012; Johnston & Carroll, 1998), and action research projects (e.g., L. Evans, Hardy, & Fleming, 2000) can enhance our understanding of the consequences of sport injury in terms of psychological functioning. especially influenced by the characteristics of the injury, such as its location and symptoms. Two personal factors thought to be particularly influential on cognitive appraisals are the athlete’s commitments and his or her beliefs about control. The commitments that a person makes to certain goals have important cognitive and motivational implications (Klinger, 1977; Lazarus & Folkman, 1984). First, they influence appraisal by directing the individual’s behavior regarding potentially threatening (and potentially beneficial) situations. For instance, in order to succeed at sport, athletes frequently elect to forego other activities that could provide their lives with greater balance. Second, an athlete’s commitments heighten her or his sensitivity to cues that may be relevant to those commitments. For example, as compared with their nonathlete peers, athletes may have greater sensitivity, or give greater weight, to physical information due to the importance of physical functioning in sport. Third, and most important, commitments are closely related to psychological vulnerability. Given that commitments determine what is important to an individual, events that threaten those commitments are appraised as particularly meaningful. In terms of sport injury, Lazarus and Folkman noted that “the extent to which . . . physical vulnerabilities . . . have implications for psychological vulnerability depends on the importance of the commitments that the physical disabilities threaten” (p. 51, emphasis added). For example, a severely sprained ankle is more likely to be appraised as a major life disruption by a tennis player B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. 65 66 Psychology of Sport Injury than by an office manager (unless, of course, the office manager is also an avid athlete). Cognitive appraisals can also be affected by both general and situational beliefs about control. General beliefs about control—which involve the extent to which one thinks that he or she can control important events and outcomes—are thought to contribute most strongly to appraisals in ambiguous or novel situations (Rotter, 1966). Therefore, athletes with an internal locus of control (i.e., who believe they generally can act to control environmental events) are viewed as more likely to appraise an ambiguous injury situation as controllable than are athletes with an external locus of control (i.e., who believe that outcomes are not generally contingent on their actions). Sport injuries, however, often occur in unambiguous or familiar situations; therefore, situational beliefs about control, which are very similar to secondary appraisals, are especially relevant to injury-related appraisals (Lazarus & Folkman, 1984). The primary situational factors thought to affect cognitive appraisals are novelty, predictability, event uncertainty, temporal (time) factors, ambiguity, and timing of the event in the athlete’s life cycle (Lazarus & Folkman, 1984). Even for athletes who have not previously been injured, an injury is likely to be appraised as a kind of harm or loss due to the well-known debilitating effects of injury on sport performance. Knowledge of the course of an injury may increase both predictability and the athlete’s feelings of control and thus lead to a less threatening appraisal of the situation. An appraisal is likely to be influenced by event uncertainty when the athlete is unsure whether an injury has occurred (e.g., “Is my leg pain symptomatic of a fractured bone?”). The temporal factor that is most relevant to appraisals associated with sport injury is duration; for instance, a short-term injury might be less likely than a chronic condition would be to produce a stress appraisal. As noted earlier, ambiguous situations invoke appraisals based on general beliefs about control. Finally, the appraisal process may be particularly influenced by the timing of an injury in the athlete’s life cycle. Consider the example of an athlete whose sport career is ended in its prime by an injury. If the athlete had planned on participating in sport for many more years, an appraisal of harm and loss might be especially likely. Attributions for Injury When people encounter unexpected events, they tend to think about what might have caused them (Wong & Weiner, 1981). In other words, they tend to make attributions for the causes of the events. Among other things, this kind of attributional cognitive activity is stimulated by the usually unanticipated and often traumatic experience of sustaining a sport injury. Athletes generally have little trouble generating attributions for the causes of their injuries. For example, athletes in two studies (San José, 2003; Tedder & Biddle, 1998) tended to identify behavioral factors as causing their injuries, whereas athletes in a third study (Brewer, 1999a) tended to attribute their injuries to mechanical or technical factors. Because causal attributions are essentially situational beliefs about control, it would be expected that locus of control (i.e., general beliefs about control) and situational factors (e.g., social context) influence athletes’ causal explanations for their injuries. Cognitive Content The generally unanticipated, often traumatic nature of sport injury may also produce images associated with the injury event that recurringly invade the athlete’s mental space and are experienced by the athlete as disturbing (McArdle, 2010; Newcomer & Perna, 2003; Shuer & Dietrich, 1997; Vergeer, 2006). In one study (Shuer & Dietrich), athletes with chronic injuries reported having intrusive thoughts at a level below that of people who had been in an earthquake but comparable to that of people who had been in a fire. In addition, the athletes reported trying to avoid thoughts associated with their injuries to a greater extent than people who had been in a fire or earthquake did with thoughts about their respective traumatic events. Although one might expect intrusive injury-related thoughts—and the avoidance of such thoughts—to dissipate over time (Vergeer, 2006), Shuer and Dietrich reported no B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. Psychological Responses to Sport Injury   67 significant differences in intrusion and avoidance among athletes with injuries of different durations, ranging from less than one week to more than a year. Intrusive injury-related images can have ramifications for both psychological and physical functioning. Appaneal, Perna, and Larkin (2007) demonstrated that relative to athletes without injuries, athletes who had recently sustained a severe sport injury responded with greater self-reported distress and skinconductance reactivity when exposed to video content related to traumatic injury. Self-Related Cognition For many athletes, sport serves as a source of self-worth and self-definition (Brewer, Van Raalte, & Linder, 1993), and injury—which poses a threat to sport involvement—can affect thoughts about the self. With respect to self-esteem, studies have shown that injured athletes have lower global self-esteem than do athletes without an injury (Chan & Grossman, 1988; Kleiber & Brock, 1992; Leddy et al., 1994; McGowan, Pierce, Williams, & Eastman, 1994) and that athletes experience decreased global and domain-specific physical self-esteem after becoming injured (Leddy et al.). In addition, athletes with chronic injuries have reported lower levels of global self-esteem than athletes with acute injuries (Wasley & Lox, 1998), a finding which suggests that injury duration (a personal or injury-related factor) is associated with self-related cognitions. Similarly, illustrating the potential relevance of personal factors to self-perceptions following injury, Kleiber and Brock (1992) found that among athletes who had incurred a career-ending injury, those who were highly invested in playing professional sport had lower self-esteem than those without that aspiration. Presumably, the athletes who were highly invested in playing sport professionally were more likely to appraise their injuries as threatening or stressful. Changes over time after injury have been documented for the related concepts of sport self-confidence and self-efficacy. Quinn and Fallon (1999) found that injured athletes began the rehabilitation period high in sport self-confidence, declined in confidence during rehabilitation, and experienced an increase in confidence as they recovered from injury. Similarly, athletes with knee injuries (some of whom had reconstructive surgery) have reported increases in knee-specific self-efficacy across the rehabilitation period (Thomeé et al., 2007a). Other personal and injury-related factors are also (positively) associated with knee-specific self-efficacy, including internal locus of control and perceived knee functioning (Thomeé et al., 2007a, 2007b). Another aspect of self-related cognition that can be affected by sport injury is selfidentity. Brewer, Cornelius, Stephan, and Van Raalte (2010) reported that people who underwent reconstructive surgery after an ACL tear decreased their identification with the athlete role over the first two years after surgery. The decline in athletic identity was greatest between 6 and 12 months after surgery, and the largest reductions were reported by athletes who experienced the least rehabilitation progress during that period. Such modification of self-image may have been a protective response to the fact that the ACL injury threatened the athlete’s sport participation and to any difficulties experienced during postoperative rehabilitation activities. Research has documented similar changes in self-image—in which an exclusive (or at least very narrow) identification with the athlete role was replaced by a current or desired self-image reflecting a diminished focus on sport as a source of self-worth and self-description—among athletes whose physical functioning was severely hampered by injury (Vergeer, 2006) or another disabling medical condition (Sparkes, 1998). Cognitive Coping Strategies As indicated by the apparently self-protective changes in self-identity described in the preceding section, athletes need not be merely passive recipients of the physical and psychological trauma associated with experiencing a sport injury. Instead, they can initiate efforts to cope with the adverse effects of injury, and some of the coping strategies are clearly cognitive in nature. Results of qualitative research have suggested that the use of cognitive coping strategies is commonplace among injured athletes and is characterized by themes such B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics. 68 Psychology of Sport Injury as accepting injury, focusing on getting better, disengaging mentally, thinking positively, and using imagery (Bianco et al., 1999; Carson & Polman, 2008, 2010; Gould et al., 1997b; Rose & Jevne, 1993; Ruddock-Hudson, O’Halloran, & Murphy, 2014; Tracey, 2003; Udry, Gould, Bridges, & Beck, 1997; Wadey, Evans, Hanton, & Neil, 2012b). The findings from qualitative investigations are complemented by those from quantitative studies, in which athletes from a broad range of sports report using a similar set of cognitive coping strategies to deal with the consequences of injury (El Ali, Marivain, Heas, & Boulva, 2008; Quinn & Fallon, 1999; Udry, 1997). Consistent with cognitive appraisal models, the use of cognitive coping strategies has been found to vary as a function of two injuryrelated factors (injury type and phase of rehabilitation) and one personal factor (hardiness). With respect to injury type, Wasley and Lox (1998) found that athletes with chronic injuries reported using more escape-avoidance coping, which includes “wishful thinking,” than did athletes with acute injuries. In terms of phase of rehabilitation, Udry (1997) found that the amount of negative-emotion coping and palliative coping (both of which include substantial cognitive components) varied over the course of rehabilitation in a sample of athletes who had undergone knee surgery. Complementing these findings, Johnston and Carroll (2000) documented a steady decrease in the use of logical analysis, positive reappraisal, cognitive avoidance, and acceptance coping strategies over the course of injury rehabilitation. Thus, it appears that athletes may adjust their use of cognitive coping strategies in accord with fluctuations in injury symptoms and the demands of rehabilitation. Regarding the personal factor—hardiness—Wadey et al. (2012b) found that athletes who were low on that dimension tended to report using ineffective, avoidancebased strategies to cope with their injuries. Perceived Benefits of Injury Despite the frequency with which athletes make appraisals of threat and harm or loss with respect to sport injury (Ford & Gordon, 1999; Gould et al., 1997a)—and despite the psycho- logical turmoil that such appraisals can elicit— the effects of injury on cognition do not appear to be uniformly negative. Qualitative research has revealed that amidst the negativity, which can be pervasive in the cognition of injured athletes, perceptions of benefit from injury can also emerge (Almeida, Luciano, Lameiras, & Buceta, 2014; Crawford, Gayman, & Tracey, 2014; Ford & Gordon, 1999; Hurley, Moran, & Guerin, 2007; Podlog & Eklund, 2006a; Rose & Jevne, 1993; Ruddock-Hudson et al., 2014; San José, 2003; Tracey, 2003; Udry et al., 1997; Wadey, Clark, Podlog, & McCullough, 2013; Wadey, Evans, Evans, & Mitchell, 2011; Wadey et al., 2012b; J.A. Young, Pain, & Pearce, 2007). Most of the benefit-oriented themes articulated by injured athletes can be classified into the three main categories identified by Udry et al.: 1. Personal growth benefits 2. Psychologically based performance enhancement 3. Physical and technical development Personal growth benefits include gaining perspective on sport involvement, developing interests outside of sport, and becoming a more understanding person. Psychologically based performance enhancement involves benefits such as improved mental toughness, increased tactical awareness, and increased motivation. Benefits associated with physical and technical development include improved technique, enhanced health, and increased strength. Many of the perceived benefits of injury do not occur automatically upon sustaining an injury; instead, they require effort and may be realized only over time (Udry, 1999). Injury offers opportunities for benefits to be perceived and realized by athletes; it is up to them—and those who assist them—to take advantage of those opportunities. It is critical, therefore, to identify common perceived benefits of injury and determine the paths that athletes can follow to obtain them. In an exceptionally thorough investigation of perceived benefits of sport injury, Wadey et al. (2011) examined the perceived antecedents and underlying mechanisms of perceived benefits of sport injury with a sample of 10 team- B.W. Brewer and C.J. Redmond, Psychology of Sport Injury, Champaign, IL: Human Kinetics, 2017). For use only in Psychology of Sport Injury Course 2–Sport Medics.