Confidence and return to sport following injury: a critical evaluation
Psychological factors and their influence on return to sport (RTS) following injury is receiving growing interest in the literature. There are many psychological factors associated with RTS, and these are commonly grouped into cognitive, emotional and behavioural factors.1
Traditionally the decision to RTS following injury has been based on clinical, functional and sports-specific measures, with little or no consideration given to an athletes psychological state.2 This is despite our understanding that when an athlete sustains an injury it has both physical and psychological impacts.3 The readiness of physical and psychological factors in RTS may not coincide,4 meaning athletes may return to training or competition when they are physically but not psychologically ready. This can lead to fear, anxiety, reinjury, injury to different body parts, depression and a decrease in performance.5
Confidence, a psychological factor often categorised within cognition, has been associated with a greater likelihood of returning to preinjury levels of participation and expediting resumption of competitive activities.6 It pertains to the cognitive and emotional responses that contribute to an athletes perception of their proficiency or effectiveness in sports participation.6,7 A successful RTS transition has been associated with feelings of sport-related confidence which can concern both the injury and performance.6,7,8
Several studies have reported that having confidence in the injured limb is crucial for successful RTS following Anterior Cruciate Ligament (ACL) reconstruction.8,9,10 In a study of two hundred and twenty participants completing the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) Scale after reconstruction, confidence in the injured limb was more of a concern to subjects than confidence in their general performance.9 Fear was identified as the primary reason for athletes failure to RTS.9 A main aim for professional rugby union players before returning to competition post ACL reconstruction, was to build confidence in the injured limb, through injury and performance specific inputs.8 A prospective longitudinal study of eighty-seven ACL reconstructed athletes studied psychological factors at multiple rehabilitation time points not just the RTS stage.10 Using the ACL-RSI scale they found a significant difference in results when comparing athletes successfully RTS and those that had not returned. More positive emotions, including confidence related to their injury, were experienced in returning athletes at six months before RTS (p=0.005) and twelve months (p=0.001), supporting the findings of Carson & Polman.8
The studies discussed thus far all suggest confidence in the injured limb is associated with RTS outcomes, however the disparity in study designs and methodologies make it a challenge to draw meaningful conclusions. One study captured data through a qualitative design using a pre-designed diary concurrently with the RTS process and semi-structured interviews.8 This may provide richer data and give a highly practical understanding of RTS following injury, compared to the other studies using a prospective design, gathering quantitative data.9,10 The difference in samples also challenges, in that two studies used large numbers, but subjects of varying athletic ability, with one using recreational the other competitive athletes, and age ranges from 16-54 years within the studies. This age range does not account for potential age-related differences that have previously been reported in respect to injury responses and rehabilitation.11 The study by Carson and Polman8 used a homogenous sample, all professional athletes whom had an ACL reconstruction, which gives strength to the findings in that they are relevant to professional athletes, who’s experiences may be very different from recreational athletes. However, the low subject numbers of five athletes does limit the power of this study.
The research conducted in ACL reconstruction populations gives a narrow prospective and precludes any generalisation of the findings. Two studies have allowed for this by studying populations with different injuries and reporting on both confidence in the injury and performance.12,13 In a qualitative study athletes experiences and understandings of psychological readiness to RTS were examined following a serious injury, with confidence reported as a major attribute of psychological readiness to RTS.12 However this study, similar to that by Carson and Polman8 only had a small sample of seven subjects. They were from team and individual sports, ranging from club to professional level and three athletes had yet to return to competition, so were unable to comment on RTS outcomes. Again this poses a challenge in extrapolating meaning from this data although it potentially highlights the reality and challenges with this research area. Although this study was compromised, it still provided some valuable information, highlighting confidence being multidimensional, and RTS being associated with the prescribed rehabilitation programme, the injured body part and performance capability beliefs.
The multi-dimensional nature of confidence was captured when assessing the reliability and validity of a scale to measure psychological readiness in RTS following injury.13 Subjects were national collegiate level and entry to the study was once subjects athletic trainers had reported they would miss sporting practice for at least one week due to injury. This shorter injury duration makes study comparison difficult, as injury severity often measured through time loss can be very influential in psychological readiness.1 However this study addressed the problem with self-report inventories and affective scales where respondents may not be truthful and answers given biased, by getting the athletic trainers to also rate athlete confidence levels. This may be an approach worthy of consideration in future research. Critique aside, considered in an entirety this study highlighted that confidence in relation to the injured body part and ability to perform is essential in ensuring athletes are psychologically prepared to resume competitive activities, supporting previous findings.12
It appears that successful RTS following injury is under-pinned by developing self-confidence cognitions, in the injured body part and the ability to perform.12 For practitioners, understanding the precursors in developing confidence in RTS may help in planning and delivering rehabilitation strategies. These precursors have been identified as having trust in the rehabilitation provider, satisfaction of social support networks and achievement of physical standards/clinical outcomes.12 These can be satisfied through interventions such as goal setting,7 visual imagery 6 and strong social support.4,7
To conclude confidence appears multidimensional in nature and a key factor in psychological readiness. From the research considered it can be concluded that confidence in the injured limb and sporting performance are associated with RTS outcomes. To draw further conclusion would require research with larger sample sizes and comparable populations from a range of sports, to give opportunity for further exploration of the conclusions drawn here.
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