Athletic Insight - The Online Journal of Sport Psychology

The Effects of Cognitive and Relaxation Interventions on Injured
Athletes’ Mood and Pain during Rehabilitation

Airi Naoi, Ed.D.
Kinki University

&

Andy Ostrow, Ph.D.
West Virginia University

ABSTRACT

Introduction

Method

Results

Discussion

References

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ABSTRACT

The purpose of this study was to assess the effectiveness of cognitive and relaxation interventions on mood and pain for a sample of college athletes who had experienced more than 12 weeks for complete recovery after surgeries. The total number of participants was five injured athletes (three males and two females), and they were members of athletic teams at mid-Atlantic universities. The A-B-C-A multiple-baseline single-subject designs across participants were used, and all participants were exposed to a baseline period (A), two interventions (B and C), and a return baseline period (A2). Dependent variables were mood and/or pain intensity. The results showed that three participants might have had improved mood score as a result of receiving the cognitive intervention. Additionally, it appeared that three participants displayed improvement in either mood and/or pain during the relaxation intervention. The results of the study were somewhat inconsistent across participants; thus, the results were examined more carefully on an individual basis.

Introduction

       In the past 10 years, the amount of research conducted in the psychological aspects of sport injury has increased (Wiese-Bjornstal, 2004). In order to understand psychological response following athletic injury, some researchers have established models (Brewer, 1994; Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998). Initially, researchers adopted the stage model to understand psychological response after sport injury (O’Connor, Heil, Harmer, & Zimmerman, 2005). The stage model established by Kübler-Ross (1969) explained that individuals with a terminal illness and/or experiences of grief and loss go through five stages: (1) denial, (2) anger, (3) bargaining, (4) depression and (5) acceptance. Hardy and Crace (1990) indicated that emotional reaction after injury has two phases: a reactive phase and adaptive phase. The reactive phase includes shock and negative emotions such as denial, anger, and depression, and the adaptive phase includes positive emotion such as acceptance, hope, confidence and vigor.

       However, it is difficult for stage models to account for individual differences in response to athletic injury (Brewer, 1994). In order to respond to these differences, two researchers developed models to focus on the cognitive appraisal of psychological adjustment. First, Brewer established a cognitive appraisal model of psychological adjustment to athletic injury. According to this model, injured athletes’ personal factors and situational factors influence their cognitive appraisal. Cognitive appraisal was emphasized in this model because athletes’ emotional responses to injury are determined by their interpretation of injury rather than the severity of the injury itself. Then, emotional response further determines the behavioral responses such as rehabilitation adherence and compliance with rehabilitation. Second, Wiese-Bjornstal et al. (1998) also established an integrated model of response to sport injury and the rehabilitation process. This model also indicates that both personal factors and situational factors influence cognitive appraisal (i.e., goal adjustment, rate of perceived recovery), and cognitive appraisal further determines emotional responses (i.e., tension, anger, and depression) and behavioral responses (i.e., adherence to rehabilitation, use of PST strategies). These three domains (i.e., cognitive appraisal, emotional response, and behavioral response) are dependent on each other and changes in one of these three domains will have bearing on functioning within the other domains and can subsequently influence recovery outcome. Coping also influences the response to sport injury and the rehabilitation process (Wiese-Bjornstal et al). There are two types of coping: problem focused and emotional focused (Weinberg & Gould, 2003). Problem focused coping is when individuals make efforts to alter or manage the problem that causes the stress. Emotional focused coping is when individuals regulate emotional responses by using techniques such as relaxation, meditation, and cognitive efforts to modify the meaning of the situation. Unlike problem focused coping emotional focused coping does not focus on the actual problem and environment.

       Previous research has indicated the prominence of emotional distress among injured athletes (Leddy, Lambert, & Ogles, 1994; Smith, Scott, O’Fallon, & Young, 1990; Weiss & Troxel, 1986). For example, injured athletes commonly experience tension, depression, and anger (Smith et al.) and injured athletes have exhibited higher depression scores than non-injured athletes and recovered athletes (Leddy et al.). Additionally, 47% of athletic trainers reported that athletic injuries influence athletes psychologically as well as physiologically (Larson, Starkey, & Zaichkowsky, 1996). In particular, mood disturbance was observed after anterior cruciate ligament (ACL) surgeries among injured athletes, and there was no improvement in their mood disturbances from pre-surgery to three weeks after their surgery (Udry, 1997). Research indicates that these three responses may be inter-linked. In another research study (Daly, Brewer, Van Raalte, Petitpas, & Sklar, 1995) it was found that when injured athletes experienced emotional distress such as anger and depression, they were reluctant to attend physical rehabilitation sessions. Further, when pain and anxiety were reduced, athletes’ compliance with physical rehabilitation increased (Ross & Berger, 1996). Therefore, it may be important to provide psychological interventions after injury and surgery to help injured athletes cope with negative emotions.

       In addition to relationship between cognitive, emotional, and behavioral responses, optimism is another factor that may influence injury recovery, and dispositional optimism may be an important “mediator variables.” Dispositional optimism was defined as generalized outcome expectancies (Scheier & Carver, 1985). Different coping styles between optimists and pessimists were reported (Scheier, Weintraub, & Carver, 1986). Optimists used more positive coping such as problem-focused coping, seeking social support, and emphasizing positive aspects of the stressful situation, while pessimists used denial and distancing. The optimism v.s. pessimism conceptualization and attribution theory explain that consequences of optimism v.s. pessimism are resulted from the differences between people’s expectancies, and optimists are more likely to use positive reinterpretation and accept the reality of the situation (Scheier & Carver, 1992). Researchers have found a positive relationship among optimism, mood, and the immune system that includes higher levels of helper T-cells and the natural killer cell cytotoxicity in law students (Segerstrom, Taylor, Kemeny, & Fahey, 1998). Additionally, dispositional optimism was also associated with an improved recovery rate among patients who had coronary artery bypass surgery (Scheier et al., 1989). However, optimism has not been assessed in injured athletes in previous research.

       There are several studies that have investigated the effectiveness of psychological interventions during injury rehabilitation. A study found that counseling skills interventions (e.g., active listening skills, challenging negative beliefs and assumptions, exploring coping strategies) provided sources of emotional, listening, and informational support for two of three competitive athletes after they underwent ACL reconstruction surgery (Rock & Jones, 2002). Furthermore, Cupal and Brewer (2001) facilitated relaxation and guided imagery sessions for injured athletes who went through rehabilitation for ACL reconstruction. The results found that injured athletes who received ten breath-assisted relaxation and guided imagery sessions significantly reduced reinjury anxiety and pain when compared to injured athletes in the placebo group and the control group at 24 weeks post-surgery. Additionally, a study examined the effect of psychological interventions in 58 competitive athletes with long-term injuries (Johnson, 2000). It was found that psychological-interventions (e.g., goal setting, cognitive control, relaxation/guided imagery) helped reduce negative moods, while expediting return to competition.

       In order to reduce injured athletes’ emotional distress, cognitive interventions can play an important role. Injured athletes may feel panic and helplessness as a result of engaging in irrational and negative thoughts (Weiss & Troxel, 1986); therefore, they should be encouraged to use positive statements during rehabilitation. Taylor and Taylor (1997) reported that using positive statements at the beginning and end of each rehabilitation session is recommended because it can generate positive emotions that improve the quality of the rehabilitation. Physiotherapists reported that encouraging positive self-thoughts is a more important strategy in treating injured athletes than mental imagery and relaxation (Ninedek & Kolt, 2000). In addition, a recent study reported that there was a positive relationship between the use of positive self-talk and home exercise completion in injured athletes who undertook ACL rehabilitation (Scherzer et al., 2001). It has also been found that cognitive-behavioral interventions such as self-monitoring of cognitive and emotional indicators of distress, relaxation, positive coping statements, and self-reinforcement statements helped injured athletes reduce anxiety and pain, and sped up their healing process (Ross & Berger, 1996). Ross and Berger assessed the effects of a cognitive-behavioral intervention on postsurgical anxiety and pain after meniscus injury in 60 male athletes, whose ages ranged from 18 to 55 years and found that a cognitive-behavioral intervention helped injured athletes reduce anxiety and pain, and sped up their recovery rate. Despite these studies, the research examining the effectiveness of cognitive-behavioral interventions in the rehabilitation process is limited.

       Relaxation training has been found to be another important psychological intervention to reduce pain and tension in injured areas and release psychological distress (Shaffer & Wiese-Bjornstal, 1999). The stress of being injured may increase muscle tension in the injured areas (Ievleva & Orlick, 1999), and it may also increase perception of pain (Shaffer & Wiese-Bjornstal). Autogenic training can help individuals reduce anxiety, irritability, and fatigue (Davis, Eshelman, & Mckay, 1995). This intervention also helps individuals modify reactions to pain, increase the ability to deal with stress, and reduce sleep disorders (Davis et al., 1995). However, there are few research studies that have assessed the effectiveness of autogenic training in the rehabilitation of injured athletes, although it has been successfully used as an effective treatment for other populations such as chronic pain patients (Newton-John, Spence, & Schotte, 1995) and patients diagnosed with chronic tension headaches (Spinhoven, Linssen, Van Dyck, & Zitman, 1992).

       In addition to autogenic training, previous research studies have included breathing as a psychological intervention for injured athletes (Johnson, 2000; Ross & Berger, 1996). According to those studies, a psychological intervention that included relaxation strategies (i.e., deep breathing and imagery) significantly reduced emotional distress (Johnson; Ross & Berger) and pain intensity, and sped up recovery time (Ross & Berger). However, these researchers combined both a cognitive intervention and a relaxation intervention; therefore, it is unclear which intervention may have had the most impact for the injured athletes.

       In examining and contrasting the role of psychological interventions on the rehabilitation process, the single-subject designs may be quite useful. Single-subject designs allow all participants to be exposed to the baseline and the interventions while data is collected repeatedly (Hrycaiko & Martin, 1996), so the effect of the interventions can be appropriately examined. For example, in the single subject designs, all the participants’ data was collected without intervention during the baseline period; then, all participants received the intervention during the intervention period. While the between group design divides participants into the control group (no intervention) and the experimental group (with intervention), the single subject designs provide all the participants opportunity to experience the interventions. Single-case research designs allow participants to serve as their own controls, so the researcher can compare the subject’s performances in different conditions (Kazdin, 1982). When considering individual differences, researchers can benefit from utilizing a single-case research design in comparison to group research. According to Kazdin, “Information from group research is important but it excludes vital information of the individual” (p. 7). In contrast, single-case research designs help researchers find important information about the uniqueness of the participants (Kazdin). Barlow and Hersen (1984) explained that “If we ignore differences among individuals and simply average them into a group mean, it will be more difficult to estimate the effects on the next individual, or “generalize” the results” (p. 49). Additionally, the design lends itself well to investigations in applied settings. The procedures in single-case research designs are similar to the clinical setting, where the participants receive the treatment or intervention, and the data collected in this phase helps the researcher understand each participant’s responses to the intervention (Barlow & Hersen). There are a number of examples of effective use of single-subject design methodology in the area of sport psychology (Landin & Hebert, 1999; Thelwell & Greenlees, 2003), and the use of single-case research design has been recommended by researchers as a way to examine the effectiveness of psychological interventions on sport performance (Bryan, 1987; Wollman, 1986). Therefore, the single subject design should be valued in order to understand individual needs of individual athletes and the effectiveness of psychological interventions on injury recovery.

       The purpose of this study was to investigate and compare the effectiveness of cognitive intervention and relaxation intervention on injured athletes’ pain and mood. It was hypothesized that if an intervention was effective, the injured athletes would have improvements in mood (i.e., tension, anger, and depression) and experience reduced pain intensity. A secondary purpose of this study was to examine if optimism influenced the effectiveness of both interventions. It was hypothesized that the participants with high optimism would respond to the interventions more positively than the participants with low optimism.

Method

Participants and Recruitment

       The total number of participants who completed this study was five injured athletes (three males and two females) (M age = 20, SD = 1.41). They represented one NCAA Division I university (n = 4) and one NCAA Division II university (n = 1), and the sports of track, baseball, soccer, and basketball. The criteria for participation in the investigation were as follows: (1) the participants required more than eight weeks for complete recovery after surgery or injury occurrence, (2) the participants needed to return to competition during the season or next season, so senior athletes who had a season ending injury were excluded, and (3) when pre-tested, participants needed to score at least 0.5 standard deviation higher than college normative data on the Profile of Mood States (POMS: McNair, Lorr, & Droppleman, 1992), a measure of mood disturbance.*

       The types of injuries reported were anterior cruciate ligament (ACL) reconstruction, ulnar collateral ligament (UCL) reconstruction, fractured tibia and fibula, and meniscus tear. All of the participants had undergone surgery for their injuries, and ended up needing more than 12 weeks for complete recovery after their surgeries. All athletes participated in the study within one week after their surgeries. Each participant received a total of $40 for participation in this study. In addition, six athletic trainers from the two universities also participated in this study in order to examine the athletes’ injury types and expected recovery rates. Approval from the Institutional Review Board (IRB) for the Protection of Human Subjects was obtained before conducting this study, and informed consent was obtained from each participant.

Research Design

       This study utilized an A-B-C-A multiple baseline design across participants. All participants were exposed to a baseline period (A), two interventions (B and C) (i.e., a cognitive intervention and a relaxation intervention), and a second baseline period (A2). The order of the two interventions was counterbalanced across participants. The multiple baseline design assessed the effects of the cognitive intervention and the relaxation intervention by introducing these interventions to each athlete at different points in time. Participants received the first intervention when their mood disturbance reached a stable level during the baseline period. In order for an intervention to begin for a participant, at least four consecutive data points of the sum score of anxiety, depression, and anger on the Brief Assessment of Mood measurements (BAM: Dean, Whelan, & Meyers, 1990) had to have a visually discernible slope of approximately zero. The sum score of anxiety, depression and anger on the BAM was used to assess stability because participants’ class schedules and rehabilitation menus influenced their fatigue and energy levels, and a previous research study found that tension, depression, and anger were three mood states that differentiate non-injured athletes from injured athletes (Smith et al., 1990). The length of the baseline period was different for each athlete.

       The dependent variables were measures of mood disturbance and pain intensity. Participants took approximately 6 to 10 weeks to complete this study with each intervention lasting two weeks. The average length of this study was 8.3 weeks. The independent variables of this study were the cognitive intervention and the relaxation intervention.

Instrumentation

Personal Information Sheet

       The Personal Information Sheet included demographic questions related to participants’ age, gender, race, academic year, sport, scholarship status, date of injury, expected recovery date, athletic season, injury history, and usage of psychological skills training.

Profile of Mood States

       The Profile of Mood States (POMS), developed by McNair et al. (1992), measures six affective states: (1) tension/anxiety (TEN), (2) depression/dejection (DEP), (3) anger/hostility (ANG), (4) vigor/activity (VIG), (5) fatigue/inertia (FAT), and (6) confusion/bewilderment (CON). The POMS consists of 65 five-point adjective rating scales, and each item of the POMS is answered on a five-point Likert scale “not at all,” “a little,” “moderately,” “quite a bit,” and “extremely.” In this study, a Total Mood Disturbance (TMD) and three of six subscales, Tension, Depression, and Anger, were used to analyze emotional distress. In order to calculate the TMD, all components of affective states except vigor are added, and vigor score is subtracted from the sum score. Reliability and validity have been established for the POMS (McNair et al.).

Brief Assessment of Mood

       Even though the POMS is a common method of measuring mood, it is not feasible to administer it on a daily basis because of its length. Therefore, the Brief Assessment of Mood (BAM) was also employed which reduces the 65 items of the POMS to six items. In a sample of 694 college students, the BAM Total Mood Disturbance (BTMD) and the POMS Total Mood Disturbance (PTMD) were significantly correlated (r = .88, p < .001), and the Cronbach’s coefficient alpha for the BTMD was acceptable (a= .75) (Dean, Whelan, & Meyers, 1990). The BAM takes approximately 10 to 15 seconds to complete, so this is a more practical assessment of mood disturbance in a rehabilitation setting.

Short-Form McGill Pain Questionnaire

       The Short-Form McGill Pain Questionnaire (SF-MPQ: Melzack, 1987) was used because it requires less time to acquire the data than the McGill Pain Questionnaire (MPQ: Melzack, 1975). The SF-MPQ contains 15 word descriptors and measures subjects’ pain in sensory and affective categories. The SF-MPQ uses a four-point Likert-type scale, and responses range from “none” to “severe.” The SF-MPQ includes two measurements of pain intensity, the present pain intensity (PPI) and the Visual Analogue Scale (VAS). Previous studies have supported the validity of the SF-MPQ (Dudgeon, Raubertas, & Rosenthal, 1993; Melzack, 1987).

Visual Analogue Scale

       The Visual Analogue Scale (VAS), a written self-report method of rating pain, was employed five days a week in addition to the SF-MPQ which was administered once a week. The VAS only has one question; therefore, it is more practical than the SF-MPQ for frequent assessment in a rehabilitation setting. Injured athletes marked X at a point on a continuous 100 millimeter (mm) line that represents a range from “no pain” to “worst possible pain” (Heil, 1993). This scale provides 101 data points corresponding to the number of millimeters on the scale (from 0 to 100), so it is more precise psychometrically than a 10-point pain scale (Heil). Reliability and validity have been established for the VAS (Price, McGrath, Rafii, & Buckingham, 1983; Woodforde & Merskey, 1972).

Revised Life Orientation Test

       The Revised Life Orientation Test (LOT-R: Scheier, Carver, & Bridges, 1994) assesses generalized sense of optimism, and it was scored unidimensionally. The LOT-R consists of 10 items, and four of the items are filter items and are not scored. The LOT-R uses a four-point Likert-type scale, and responses range from “strongly disagree” to “strongly agree.” Three items are scored in a positive direction, and three items are scored in a negative direction. Reliability and validity have been established for the LOT-R (Scheier et al.).

Post Test

       The post test assessed participants’ use of positive self-statements, and their perceptions of the effectiveness of both the cognitive and relaxation interventions on their psychological and physical recovery. Additionally, their perception of recovery rate was measured. Athletes were also asked about their usage of positive self-statements and relaxation skills during the second baseline period to ensure they had stopped using all the skills.

Procedures

Initial Contact with Athletic Trainers

       Prior to conducting this study, one of the researchers explained to the athletic trainers the purposes of this study, relevant information such as the criteria for inclusion of participants, and the method of administering the assessments and interventions. When the injured athletes met the eligibility criteria, athletic trainers were asked to contact the researcher.

Assessment

       At the first meeting (pre-test), each participant completed an informed consent statement, the personal information sheet, the POMS, BAM, SF-MPQ, VAS, and LOT-R. The researchers asked participants’ athletic trainers completed an informed consent statement, and provided information regarding the athletes’ type of injury and expected recovery rate. The POMS, BAM, SF-MPQ, VAS, LOT-R, and a question related to compliance before rehabilitation sessions were also administered once a week and at the end of each phase of the research design. Then, the athletic trainers administered the BAM and the VAS daily prior to any treatment starting on the second day of the study. When athletic trainers were busy, the investigator administered the BAM and the VAS. The SF-MPQ included three parts, 15 word descriptors, the VAS and the PPI, but the VAS and the PPI were not analyzed since another VAS was also administered daily, and the PPI only had one question. All data were collected during school days because athletes’ moods may have been different during weekends and holidays. The investigator visited each training room at least three times a week in order to ensure the accuracy of the procedures.

Phase A (Baseline)

       A minimum of 7 and a maximum of 14 assessments of the BAM and VAS were conducted in this phase resulting in a staggered baseline. Participants continued in this baseline phase until stability was established. No interventions were conducted.

Phases B and C

       During each intervention phase, the researcher administered the cognitive intervention or the relaxation intervention. Each intervention was conducted three times a week, for two weeks with each session lasting ten minutes. The interventions were always administered after the athletes had completed a rehabilitation treatment because they could reflect on the feelings and thoughts they had during the rehabilitation, and they could relax the muscles they had worked during their rehabilitation sessions. The order of the two interventions was counterbalanced across participants to minimize ordering effects. Thus, some athletes (n = 3) first received the cognitive intervention (B) followed by the relaxation intervention (C) while the remaining athletes (n = 2) first received the relaxation intervention (C) followed by the cognitive intervention (B). When they started the second intervention, they were asked to stop using the skills taught by the researcher during the first intervention, and their usage of these skills was ensured at the end of the second intervention. Using a counterbalancing procedure helped to minimize potential order effects of administering two interventions. During the intervention phases, the researcher was blind to the participants’ scores. Each intervention was conducted at the physician’s office, the athletic trainers’ office, the conference room at the athletic training room, or the consulting room where there was a quiet environment.

Phase A2 (Second Baseline)

       The procedures of this phase were the same as noted for the first baseline, phase A. The purpose of the second baseline phase was to examine participants’ responses after both interventions were withdrawn. Before participants started this phase, they were asked to not use the skills they had learned during the cognitive intervention and the relaxation intervention phases. Most athletes had approximately the same number of data points as in the first phase A. However, some athletes had less data points (i.e., assessments) in this phase because of spring break and the Thanksgiving holiday. At the end of the second baseline phase, the participants were asked to complete the post-test questionnaires.

Intervention

Cognitive Intervention

       According to Corey (2001), cognitive interventions focus on individuals’ insights and help individuals recognize and change their negative thoughts and maladaptive beliefs. In this study, the cognitive intervention included reading positive statements, cognitive restructuring, and self-monitoring. Previous literature reported the effectiveness of reading positive statements (Taylor & Taylor, 1997), cognitive restructuring (Rock & Jones, 2002), and self-monitoring (Ross & Berger, 1996) with injured athletes. The meeting outline was as follows. (1) The researcher asked participants how they felt and thought about their lives including health, athletics, academics, and social components. During this period, the researcher established rapport with the injured athletes by using active listening including nodding, reflection, and clarification. (2) The athletes identified (wrote or stated) negative thoughts that they had experienced over the previous few days. When athletes did not come up with any negative thoughts that day, the researcher asked them, “What are some positive things going on in your life?” (3) The athletes wrote or stated any positive ways to look at the negative thoughts they had identified. The researcher helped the athletes generate sentences by focusing on the positive aspects of their injuries (i.e., recovery progress, social support, effort) that they had previously reported. (4) The athletes selected three positive statements developed by the investigator or created their own positive statements at the first session and wrote them on a card. Some sentences were selected by the investigator from the literature (Ievleva & Orlick, 1999; Taylor & Taylor, 1997; Weiss & Troxel, 1986). Samples of positive statements were “I am getting healthier and stronger everyday” (Taylor & Taylor, p.111) and “I can do it. I can beat the odds and recover sooner than normal” (Ievleva & Orlick, p. 209). (5) The athletes read sentences in front of the researcher once and read them to themselves three times. Participants had an opportunity to change these sentences throughout this phase.

       Participants kept the positive statement card, and were asked to read their statements at least once a day. The researcher monitored how many times each injured athlete read the positive statements on the card by asking them for this information at each session. The researcher also provided a notebook to each participant, and they were asked to write in the notebook what kinds of positive and negative self-statements they had everyday. The procedures for administering the cognitive intervention were supervised by a licensed psychologist.

Relaxation intervention

       Relaxation interventions aim to relax muscle and mental (Corey, 2001). The researcher introduced to the participants to relaxation techniques that combined breathing exercises and autogenic training. A relaxation CD was created by a licensed psychologist prior to this study and employed in the study. Participants used headphones to listen to the CD during the intervention, so they would not be distracted by any noises outside of the room. The investigator also provided participants with the same relaxation CD to be used at home whenever they wanted to relax. They were asked to listen to the CD at least once a day. The researcher monitored how many times injured athletes used the relaxation CD at home through follow up questions at each session. The procedures for administering the relaxation intervention were supervised by a licensed psychologist.

Data Analysis

       Visual inspection was used to analyze the data, and the effectiveness of the two interventions was examined by four characteristics associated with the single case research designs: (1) mean, (2) level, (3) trend, (4) variability. The change in mean was calculated by adding all scores of each phase and divided them by the number of assessment periods in each phase. Then, the mean score of one phase was subtracted by the mean of the next phase. The changes in level were examined by the shift or discontinuity of mood and pain intensity from the end of one phase to the beginning of the next phase. This examined the direction of immediate change across the experimental conditions. Trend evaluation showed a tendency for the dependent variables to decrease or increase systematically or consistently over time. The variability was the fluctuation in the subject’s mood and pain intensity. It was measured by assessing the standard deviations between all data points in the phase (Kazdin, 1982).

Results

       Overall, the results of the analyses showed the following: (1) three participants (P1, P4, and P5) showed improvements in mood during the cognitive intervention and (2) three participants (P2, P4, and P5) displayed improvements in mood and/or pain during the relaxation intervention. However, these results are not conclusive. It should also be noted that one participant (P3) demonstrated negative responses during both interventions. The results were somewhat inconsistent across participants; therefore, the results were examined more carefully on an individual basis.

Participant 1 (Caucasian, Female)

       Participant 1 showed decreased sum scores of anxiety, depression, and anger on the BAM and tension, depression, and anger on the POMS during the cognitive intervention, with a decrease in the mean and a downward trend from A to B (see Figure 1-1).

Interventions Injury Figure 1

Participant 2 (Caucasian, Male)

       Participant 2 displayed slightly decreased anger on the POMS during the relaxation intervention, with a decrease in the mean from A to C (see Figure 2-2).

Interventions Injury Figure 2

Participant 3 (African American, Male)

       Participant 3 showed an increased sum score of anxiety, depression, and anger on the BAM during the cognitive intervention (see Figure 3-1). He also displayed increased tension on the POMS during the cognitive intervention and increased anger on the POMS during the relaxation intervention, with an increase in the mean from B to C (see Figure 3-2).

Interventions Injury Figure 3

Participant 4 (Native American, Male)

       Participant 4 showed a decreased sum score of anxiety, depression, and anger on the BAM during the relaxation intervention with a decrease in the mean from B to C (see Figure 4-1). Additionally, he exhibited a large decrease in anger on the POMS during the cognitive intervention, with a decrease in the mean and a downward trend from A to B. During the relaxation intervention, this participant displayed decreased depression on the POMS with a decrease in the level and the mean (see Figure 4-2).

Interventions Injury Figure 4

Participant 5 (African American, Female)

       This participant displayed decreased tension, depression, and anger, and total mood disturbance on the POMS during the cognitive intervention, with a decrease in the level and the mean from C to B (see Figure 5-2). She showed decreased pain on the SF-MPQ during the relaxation intervention, with a decrease in the level and the mean from A to C (see Figure 5-3).

Interventions Injury Figure 5

Optimism

       Participants were assigned to the high optimism group or the low optimism group based on their mean of optimism measured at the first baseline period. Participants 1, 3, and 4 who all scored above the mean on dispositional optimism were placed in the high optimism group, and participants 2 and 5 who scored below the mean on dispositional optimism were placed in the low optimism group. Overall, participants’ levels of optimism were not significantly related to the effectiveness of the interventions (see Table 1). However, at the post-test, the participants in the low optimism group rated the effectiveness of the cognitive intervention on psychological recovery to be lower than the participants in the high optimism group.

Interventions Injury Table 1

       Additionally, the participants’ attitudes toward the interventions may have been influenced by their levels of optimism. At the post-test, participants were asked “what percentage of treatment sessions did you seriously read your positive self-statement.” Participant 5 who had the lowest dispositional optimism score responded with 40% while the other participant who responded with 90-100%.

Post-Test

       With reference to the participants’ perceptions of the interventions, a post-test was conducted. At the post-test, all participants rated the effectiveness of both interventions (0 = not at all to 10 = extremely effective) on their physical and psychological recovery (see Table 1). The average score of usefulness of the cognitive intervention on physiological recovery was 5.8 and on psychological recovery was 6.6. On the other hand, the average score of usefulness of the relaxation intervention on physiological recovery was 4.6 and on psychological recovery was 5.4. Overall, the cognitive intervention was found to be more helpful for both the physiological and the psychological recovery of the injured athletes. However, one participant rated the effectiveness of the relaxation intervention very low, which influenced the overall results.

       The post-test also asked the participants to list the positive self-statements that they thought were effective from the cognitive intervention. The participants chose the following statements which were provided by the researcher: “I can do it. I can beat the odds and recover sooner than normal” (Ievleva & Orlick, 1999, p. 209), “Day by day I get stronger” (Weiss & Troxel, 1986, p.108), “I give my best effort at every rehabilitation” and “I’m getting healthier and stronger everyday” (Taylor & Taylor, 1997, p. 111). In addition to those statements, participants also listed some of the statements they had generated on their own including “Use your time wisely” and “I’m glad that the hardest part of my injury is over; now I can look forward to getting stronger everyday.”

Discussion

       The purpose of this study was to assess the effectiveness of a cognitive intervention and a relaxation intervention in reducing the emotional distress and pain of injured athletes. The results indicated that three participants showed improvements in mood during the cognitive intervention. Additionally, three participants displayed improvements in mood and/or pain during the relaxation intervention. Furthermore, at the post-test, all athletes reported that the cognitive intervention helped their physiological and psychological recovery, and four participants indicated that the relaxation intervention helped their physiological and psychological recovery. This study supported the findings of previous studies (Cupal & Brewer, 2001; Johnson, 2000; Rock & Jones, 2002; Ross & Berger, 1996) regarding the effectiveness of psychological skill interventions on injured athletes during the rehabilitation process. The findings of this study suggested that each participant responded differently to each intervention. Based on the analyses of each participant’s data, there are a number of general findings that are pertinent to the discussion.

       First, the lack of congruence between the athletes’ perceptions of the effectiveness of the interventions was found at the post-test and in the actual data recorded throughout the study. Most participants perceived the effects of both interventions positively at post-test, but the data did not always show the same results. There are several potential explanations for why this incongruence sometimes occurred. One plausible explanation is the potential influence of academic problems on emotional distress. In this study, participant 3 and 4 expressed concern about academic difficulties during the cognitive intervention and participant 3 seemed more worried about his academic situation than his injury. As a result, it is possible that the mood disturbance found in those participants who were struggling in the classroom was more closely related to their academic problems than to their injuries. The positive effects of the interventions employed were more clearly observed in the participants who did not report academic problems (participant 1 and participant 5) than in the participant who was seriously concerned about his academic difficulties (participant 3). Participant 3 reported serious academic problems in the middle of the cognitive intervention, and his classes ended during the second baseline, which suggests that his academic problems might have influenced his mood disturbance during the cognitive intervention. Interestingly, two of the participants (participant 3 and participant 4) who had academic problems indicated that not being active due to injury negatively influenced their academic performance. Therefore, caution is warranted when examining the effects of various interventions on emotional distress among athletes who have serious academic problems.

       In addition to academic concerns, some external factors such as weather and the intensity and type of treatment plan may have also influenced the dependent variables in this study. Two participants indicated that the weather influenced their mood and pain. For example, they complained about the use of crutches on rainy days. They described that the rain made it difficult to walk around campus because it was slippery or difficult to hold an umbrella. One athlete reported that the cold weather aggravated his pain, and he felt more depressed on cloudy days. Additionally, some athletes reported that their rehabilitation became harder and more challenging day by day, so fatigue and pain may have been related to the treatment plan.

       Another aspect of this study that needs to be considered is whether the relationship between the investigator and the participants impacted the effects of the interventions. The investigator in this study felt that she established good rapport with participant 1 and participant 4, and the data of participant 1 and participant 4 demonstrated concomitantly the positive effects of the interventions. In addition, participant 1 and participant 4 evaluated the effects of the cognitive intervention highly, both through verbal-report and a self-report assessment at the post-test. Previous studies have reported that establishing an alliance between therapists and clients is strongly associated with clients’ compliance to treatment plans (Frank & Gunderson, 1990). Therefore, establishing a trusting relationship between the investigator and participants might be an important factor in applied research studies.

       A limitation of this study may have also influenced the results. All of the athletes had acute injuries, and acute injuries have a natural healing pattern. Table 2 indicates the participants’ TMD on the POMS at each phase. At the second baseline, the TMD mean of all the participants had not returned to the TMD mean that was calculated during the first baseline period. Therefore, this result indicates that the effects of the interventions were still been observed and/or the natural healing pattern was taking place. For four of the athletes, this result was attributable to the effects of the natural healing process on pain, and past studies have indicated that high pain intensity is a significant predictor of psychological distress (Brewer et al., 1995); therefore, improvement of mood might be somewhat associated with natural healing of injury. Previous studies have also indicated that injured athletes showed improvement on mood throughout rehabilitation (Leddy et al., 1994; Smith et al., 1990; Udry, 1996). To overcome this limitation, the researchers set the specific criteria for the inclusion of participants. Specifically, athletes who showed improved mood at the first baseline were asked to withdraw from the study before receiving the interventions, and athletes needed to show stability of mood disturbance at the first baseline before starting the interventions. Therefore, this study minimized the influence of natural healing although natural healing might have slightly impacted the results.

Interventions Injury Table 2

       Another possible limitation of this study is expectancy bias. The researcher facilitated the interventions and collected the data herself. Although she was blind to the data during the interventions, participants might have responded positively to the interventions since they knew the researcher. However, participants were asked to answer the questionnaires honestly, and they were not informed about the effectiveness of these interventions.

Practical Suggestions

       There are several practical recommendations for professionals who work with injured college athletes. In this study, some athletes (P3 and P4) expressed anger or frustration one month after surgery because of the slow recovery process and long term rehabilitation. This result supported Smith et al.’s study (1990) that showed that athletes who required more than five weeks for complete recovery reported significantly elevated levels of depression and anger at least one month after injury when compared to the college normative data. Therefore, injured athletes should be treated both psychologically and physically until they fully recover by sport psychology professionals, coaches, and athletic trainers. Furthermore, additional attention should be provided for freshmen and transfer injured athletes until they can further develop social support networks. Four participants (participant 1, 2, 3, and 5) were freshmen or transfer students, and another participant (participant 4) had just returned to college after his involvement with a semi-professional soccer team. These athletes may not have had time to establish a trusting relationship with coaches, athletic trainers, teammates, and friends. Therefore, sport medicine and sport psychology professionals should pay close attention to the psychological response of freshmen and transfer injured athletes.

       Additionally, this study provided new ideas for using psychological interventions during injury rehabilitation in college training rooms. It is usually difficult to provide psychological support to injured athletes because they do not have much time for psychological service due to multiple tasks such as completing rehabilitation and school work, and observing team practice. Therefore, this short intervention is more feasible for injured athletes. Second, athletic trainers serve as a bridge between injured athletes and sport psychology professionals because they have a trusting relationship with injured athletes. If athletic trainers can educate athletes about the usefulness of psychological skill interventions for their recovery and performance, injured athletes may be more open to utilizing psychological skills training during rehabilitation. Also, by working with sport psychology professionals, athletic trainers can make appropriate referrals when athletes show severe psychological disturbance. This referral network can also assist in preventing psychological problems before they develop in injured athletes (Brewer, Petitpas, & Van Raalte, 1999).

       Although dispositional optimism did not mediate the effectiveness of the interventions, it influenced the athletes’ perceptions and attitudes toward the cognitive intervention. Two participants (participant 2 and participant 5) who scored low on dispositional optimism also rated the effectiveness of the cognitive intervention to be low on psychological recovery compared to other participants. In addition, the participants’ attitudes toward reading positive self-statements did differ based on their levels of dispositional optimism. Participant 5, who rated low in dispositional optimism at the first baseline, did not seriously read her positive self-statements during the cognitive intervention as compared to the other participants. She had been tearful and outwardly expressive of her discomfort during the first four weeks (i.e., first baseline and relaxation intervention) of the rehabilitation due to pain. Athletic trainers repeatedly reported that they had difficulty communicating with her and motivating her during the first four weeks. These findings supported the results of a previous study that indicated that optimists used more positive coping than pessimists (Scheier, Weinbraub, & Carver, 1986). Therefore, assessing dispositional optimism might be effective for sport psychology professionals and sport medicine staff to understand athletes’ coping styles and to provide additional support for pessimistic athletes.

       In conclusion, the results of this study showed that each participant responded differently to each intervention. Repeated assessments and interventions provided insight into the reasons why athletes showed positive and negative responses in certain phases. To avoid the influence of external factors, future studies should develop assessments that measure mood disturbance solely based on athletic injury experiences. In addition, having a homogeneous sample in terms of injury type and intensity would help the researcher in making generalizations to specific classifications of injured athletes. Lastly, injured athletes may prefer one intervention over another, and certain interventions may work better during particular periods of rehabilitation. This study combined reading positive statements, cognitive restructuring and self-monitoring in the cognitive intervention and breathing and autogenic in the relaxation intervention; therefore, further studies are also necessary to examine and compare the effects of the different cognitive interventions (reading positive statements vs. cognitive restructuring) and the relaxation interventions (breathing vs. autogenic training) so that injured athletes receive an appropriate psychological intervention in minimal time for their optimal psychological and physiological recovery.

References

      American heritage college dictionary (3rd ed.). (1997). Boston: Houghton Mifflin Company.

      Barlow, D.H., & Hersen, M. (1984). Single case experimental designs: Strategies for studying behavior change (2nd ed.). Needham Heights, MA: Allyn & Bacon.

      Brewer, B.W. (1994). Review and critique of models of psychological adjustment to athletic injury. Journal of Applied Sport Psychology, 6, 87-100.

      Brewer, B.W., Petitpas, A.J., & Van Raalte, J.L. (1999). Referral of injured athletes for counseling and psychotherapy. In R. Richard, & D.M. Wiese-Bjornstal (Eds.), Counseling in sports medicine (pp.127-141). Champaign, IL: Human Kinetics.

      Brewer, B.W., Petitpas, A.J., Van Raalte, J.L., Sklar, J.H., & Ditmar, T.D. (1995). Prevalence of psychological distress among patients at a physical therapy clinic specializing in sports medicine. Sports Medicine Training and Rehabilitation, 6, 139-145.

      Bryan, A.J. (1987). Single-subject designs for evaluation of sport psychology interventions. The Sport Psychologist, 1, 283-292.

      Corey, G. (2001). Theory and practice of counseling and psychotherapy (6th ed.). Belmont, CA: Brooks/Cole.

      Cupal, D.D., & Brewer, B.W. (2001). Effects of relaxation and guided imagery on knee strength, reinjury anxiety, and pain following anterior cruciate ligament reconstruction. Rehabilitation Psychology, 46, 28-43.

      Daly, J.M., Brewer, B.W., Van Raalte, J.L., Petitpas, A.J., & Sklar, J.H. (1995). Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. Journal of Sport Rehabilitation, 4, 23-30.

      Davis, M., Eshelman, E.R., & McKay, M. (1995). The relaxation & stress reduction workbook (4th ed.). Oakland, CA: New Harbinger Publications, inc.

      Dean, J.E., Whelan, J.P., & Meyers, A.W. (1990, September). An incredibly quick way to assess mood states: The incredibly short POMS. Paper presented at the meeting of the Association for the Advancement of Applied Sport Psychology, San Antonio, TX.

      Dudgeon, D., Raubertas, R.F., & Rosenthal, S.N. (1993). The short-form McGill Pain Questionnaire in chronic cancer pain. Journal of Pain and Symptom Management, 8, 191- 195.

      Frank, A.F., & Gunderson, J.G. (1990). The role of the therapeutic alliance in the treatment of schizophrenia. Archives of General Psychiatry, 47, 228-236.

      Hardy, C.J., & Crace, R.K. (1990). Dealing with injury. Sport Psychology Training Bulletin, 1, 1-8.

      Heil, J. (1993). Diagnostic methods and measures. In J. Heil (Ed.), Psychology of sport injury (pp. 89-112). Champaign, IL: Human Kinetics.

      Hrycaiko, D., & Martin, G.L. (1996). Applied research studies with single-subject designs: Why so few? Journal of Applied Sport Psychology, 8, 183-199.

      Ievleva, L., & Orlick, T. (1991). Mental links to enhanced healing: An exploratory study. The Sport Psychologist, 5, 25-40.

      Ievleva, L., & Orlick, T. (1999). Mental paths to enhanced recovery from a sports injury. In D. Pargman (Ed.), Psychological bases of sport injuries (pp. 199-220). Morgantown, WV: Fitness Information Technology.

      Johnson, U. (2000). Short-term psychological intervention: A study of long-term-injured competitive athletes. Journal of Sport Rehabilitation, 9, 207-218.

      Kazdin, A.E. (1982). Single-case research designs. New York: Oxford University Press.

      Kübler-Ross, E. (1969). On death and dying. London: Tavistock.

      Landin, D., & Hebert, E.P. (1999). The influence of self-talk on the performance of skilled female tennis players. Journal of Applied Sport Psychology, 11, 263-282.

      Larson, G.A., Starkey, C., & Zaichkowsky, L.D. (1996). Psychological aspects of athletic injuries as perceived by athletic trainers. The Sport Psychologist, 10, 37-47.

      Leddy, M.H., Lambert, M.J., & Ogles, B.M. (1994). Psychological consequences of athletic injury among high-level competitors. Research Quarterly for Exercise and Sport, 65, 347-354.

      McNair, D.M., Lorr, M., & Droppleman, L.F. (1992). Edits manual for the profile of mood states. San Diego, CA: Educational and Industrial Testing Service.

      Melzack, R. (1975). The McGill Pain Questionnaire: major properties and scoring methods. Pain, 1, 277- 299.

      Melzack, R. (1987). The short-form McGill Pain Questionnaire. Pain, 30, 191-197.

      Newton-John, T.R.O., Spence, S.H., & Schotte, D. (1995). Cognitive-behavioral therapy versus EMG biofeedback in the treatment of chronic low back pain. Behaviour Research and Therapy. 33, 691-697.

      Ninedek, A., & Kolt, G.S. (2000). Sport physiotherapists’ perceptions of psychological strategies in sport injury rehabilitation. Journal of Sport Rehabilitation, 9, 191-206.

      O’Connor, E., Heil, J., Harmer, P., & Zimmerman, I. (2005). Injury. In J.Taylor, & G. Wilson (Eds.), Applying sport psychology (pp.187-206). Champaign, IL: Human Kinetics.

      Price, D.D., McGrath, P.A., Rafii, A., & Buckingham, B. (1983). The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain, 17, 45- 56.

      Rock, J.A., & Jones, M.V. (2002). A preliminary investigation into the use of counseling skills in support of rehabilitation from sport injury. Journal of Sport Rehabilitation, 11, 284-304.

      Ross, M.J., & Berger, R.S. (1996). Effects of stress inoculation training on athletes’ postsurgical pain and rehabilitation after orthopedic injury. Journal of Consulting and Clinical Psychology, 64, 406-410.

      Scheier, M.F. & Carver, C.S. (1985). Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychology, 4(3), 219-247.

      Scheier, M.F. & Carver, C.S. (1992). Effects of optimism on psychological and physical well-being: theoretical overview and empirical update. Cognitive therapy and research, 16(2), 201-228.

      Scheier, M.F., Carver, C.S., & Bridges, M.W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the life orientation test. Journal of Personality and Social Psychology, 67, 1063-1078.

      Scheier, M.F., Magovern, G.J., Abbott, R.A., Matthews, K.A., Owens, J.F., Lefebvre, R.C., et al. (1989). Dispositional optimism and recovery from coronary artery bypass surgery: The beneficial effects on physical and psychological well-being. Journal of Personality and Social Psychology, 57, 1024-1040.

      Scheier, M.F., Weintraub, J.K., & Carver, C.S. (1986). Coping with stress: Divergent strategies of optimists and pessimists. Journal of Personality and Social Psychology, 51, 1257- 1264.

      Scherzer, C.B., Brewer, B.W., Cornelius, A.E., Van Raalte, J.L., Petitpas, A.J., Sklar, J.H., et al. (2001). Psychological skills and adherence to rehabilitation after reconstruction of the anterior cruciate ligament. Journal of Sport Rehabilitation, 10, 165-172.

      Segerstrom, S.C., Taylor, S.E., Kemeny, M.E., & Fahey, J.L. (1998). Optimism is associated with mood, coping, and immune change in response to stress. Journal of Personality and Social Psychology, 74, 1646-1655.

      Shaffer, S.M., & Wiese-Bjornstal, D.M. (1999). Psychosocial intervention strategies in sports medicine. In R. Richard, & D.M. Wiese-Bjornstal (Eds.), Counseling in sports medicine (pp.41-54). Champaign, IL: Human Kinetics.

      Smith, A.M., Scott, S.G., O’Fallon, W.M., & Young, M.L. (1990). Emotional responses of athletes to injury. Mayo Clinic Proceedings, 65, 38-50.

      Spinhoven, P., Linssen, C.G., Van Dyck, R., & Zitman, F.G. (1992). Autogenic training and self-hypnosis in the control of tension headache. General Hospital Psychiatry, 14, 408- 415.

      Taylor, J., & Taylor, S. (1997). Psychological approaches to sports injury rehabilitation. Gaithersburg, MD: Aspen Publishers.

      Thelwell, R.C., & Greenlees, I.A. (2001). The effects of a mental skills training packages on gymnasium triathlon performance. The Sport Psychologist, 15, 127-141. Udry, E. (1997). Coping and social support among injured athletes following surgery. Journal of Sport and Exercise Psychology, 19, 71-90.

      Weinberg, R.S., & Gould, D. (2003). Foundations of sport & exercise psychology. Champaign, IL: Human Kinetics.

      Weiss, M.R., & Troxel, R.K. (1986). Psychology of the injured athlete. Athletic Training, 21, 104-109.

      Wiese-Bjornstal, D. (2004). From skinned knees and peewees to menisci and masters: developmental sport injury psychology. In M. Weiss (Ed.), A lifespan perspective (pp.525-568). Morgantown, WV: Fitness Information Technology.

      Wiese-Bjornstal, D.M., Smith, A.M., Shaffer, S.M., & Morrey, M.A. (1998). An integrated model of response to sport injury: Psychological and sociological dynamics. Journal of Applied Sport Psychology, 10, 46-69.

      Wollman, N. (1986). Research on imagery and motor performance: Three methodological suggestions. Journal of Sport Psychology, 8, 135-138.

      Woodforde, J.M., & Merskey, H. (1972). Some relationships between subjective measures of pain. Journal of Psychosomatic Research, 16, 173-17.

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Footnote: * The mean of total mood disturbance measured by the POMS should be higher than 5.63 (male athletes) or 6.13 (female athletes) or the mean of the sum of tension, depression, and anger scale scores measured by the POMS should be higher than 4.2 (male athletes) or 4.41 (female athletes).

Correspondence concerning this article should be sent to Airi Naoi, Ed.D., Institute of Health and Sports Science, Kinki University, 3-4-1 Kowakae, Higashi-Osaka, 577-8502, Japan, airinaoi@kindai.ac.jp, Tel 81(6)6721-2332, Fax 81(6)6726-5202

Acknowledgements: The authors would like to thank Andrew Hawkins and Daniel Hursh for their help in analyzing the data; Edward Etzel for his supervision during the interventions; and Randy Meador, Kevin Kotsko and other athletic trainers at West Virginia University, California University of Pennsylvania, and West Virginia Wesleyan College for their assistance in collecting the data. The authors would also like to thank Samuel Zizzi, Heather Deaner, and Emma Grindley for their support with this study.

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