physiotherapists' and male professional athletes' views on psychological skills for...

Physiotherapists' and Male Professional Athletes' Views on Psychological Skills for Rehabilitation

Susan R Francis 1, Mark B Andersen i & Paul Maley 2

1Victoria University, Australia. 2National Basketball League, Australia.

Francis, S.P~, Andersen, M.B., & Maley, P. (2000}. Physiotherapists' and male professional athletes' views on psychological skills for rehabilitation Journal of Science and Medic#le in Sport 3 {1): 17-29.

In the literature on the psychological aspects of rehabilitation from athletic injury, several studies in North America have focused on athletic trainers' roles as physical and psychological caregivers for injured athletes. Wiese, Weiss, and Yukelson (1991) examined the views of athletic trainers on the psychological characteristics that distinguished athletes who coped well, versus those who coped poorly with rehabilitation, and also sought athletic trainers opinions on the role of psychological skills in injury rehabilitation. This study replicated the Wiese et al. (1991) study with Australian physiotherapists and extended it to include the viewpoints of professional basketball players. The results indicated the importance attached to communication and motivation by both physiotherapists and athletes in the rehabilitation process. Both athletes and physiotherapists did not, however, thJ~ak psychological skills such as relaxation or imagery techniques to be particularly useful tools in the recovery process.

I n t r o d u c t i o n Researchers iiave proposed that psychological techniques such as goal setting (Danish, 1986; Wiese & Weiss, 1987; Williams & Roepke, 1993) and counselling (Eldridge, 1983; Lynch, 1988; Smith, Scott, & Wiese, 1990) can facilitate athletic injury rehabilitation. In a recent study, Brewer, Jeffers, Petitpas, and Van Raalte (1994) examined athletes' perceptions of the value of psychological interventions in recovery from injury and found positive attitudes of athletes for the three techniques of goal setting, imagery, and counselling, bu t with greater preference for goal setting.

Ievleva and Orlick (199t) found that athletes who were fast recoverers demonstrated high scores on goal setting and other psychological factors such as positive self-talk and healing imagery. These results, coupled with the findings of Brewer et al. (1994), are encouraging in regard to the possibility of psychological techniques facilitating injury rehabilitation in athletes. At present, there have been few controlled studies examining the effects of psychological interventions on injury recovery (see Durso-Cupal, 1998). A recent area of focus, however, has been the opinions of athletic trainers on the value of psychological techniques in sport injury rehabilitation. In North America, athletic trainers are the primary caregivers for injured athletes (Larson, Starkey, & Zaichkowsky, 1996), and researchers have

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Physiotherapists' and Male Professional Athletes' Views on Psychological...

suggested that athletic t rainers are in the best position to address the psychological aspects of injury with athletes (Pedersen, 1986; Tuffey, 1991; Weiss & Troxel, 1986; Wiese & Weiss, 1987; Wiese, Weiss, & Yukelson, 1991). To ascertain the extent to which psychological principles are applied to injury rehabilitation, Wiese et al. I1991) surveyed the opinions of athletic trainers. This study revealed that athletic trainers perceived athletes who coped most successflally with injury to have a willingness to listen, a positive attitude, int.~asic motivation, and a vdllingness to learn abou t the injuly and rehabilitation techniques. The most successful psychological techniques in facilitating injury recovery were perceived to be good interpersonal communication skills, positive reinforcement, coach support, and keeping the athlete involved with the team. Finally, athletic trainers believed it important to have knowledge about using a positive communication style, have strategies for setting realistic goals, know methods for encouraging positive self-thoughts, and have an understanding of individual motivation. Interestingly, the techniques advocated by previous researchers as being useful in athletic injury treatment, such as relaxation and imagery (Tuffey, 1991; Wiese & Weiss, 1987), were not rated as particularly effective or desirable to have knowledge about by athletic trainers. These results, however, m a y represent a lack of understanding as to the application of these techniques in a rehabilitation setting. Also, this study was on athletic trainers in North America and may not be generalisable to physiotherapists practicing in Australia.

Furthermore, Gordon, Milios, and Grove (1991) investigated the opinions of Australian and New Zealand sports physiotherapis ts in regard to the psychological aspects of injury rehabilitation. Physiotherapists viewed athletes who communicated well, asked questions abou t rehabilitation, listened well to advice, and provided feedback as haxdng a positive psychological response to injury. Other factors thought to affect the psychological response of athletes to injury were severity of injury, intensity of sport involvement, and timing of injury, particularly ff injury OCCUlTed prior to a major event. The most important finding of this study, however, was tha t a large majority of sport physiotherapists felt they had limited competence to deal with the psychological aspects of rehabilitation, and most wanted access to fur ther training in the area. Although the s tudy was limited by geography and sample considerations, it was well-designed and Gordon et al.'s results echoed those of Wiese et al. (1991) and Larson et al. (1996).

Ford and Gordon (1993, 1997, 1998), in a series of related studies, examined the role of social support for athletes during injury recovery and the types of support sport physiotherapists could provide. They also found, from sport physiotherapists' viewpoints, tha t anxiety and frustration among injured athletes were common, that psychological skills training would help sport physiotherapists deliver more effective service, and that athletes' self-presentational styles had an impact on the support they received from the physiotherapists. In their latest study, they suggested that psychological training for sport physiotherapists should be expanded.

Gordon and Lindgren (1990) and Pearson and Jones (1992) have conducted qualitative (case study, in-depth interviews) and quantitative (questionnaires) investigations and have reached similar conclusions to the studies cited above. That is, negative emotional responses to sport injury can occur and that physiotherapists are in an ideal role to help athletes deal with psychological

18


sequelae of injury, bu t more training in the area is needed. In a better controlled, and statistically more sound, study of psychological distress among patients at a sports medicine clinic, Brewer, Petitpas, Van Raalte, Sklar, and Ditmar (1995} concluded that psychological distress was not a frequent occurrence among sports medicine patients, bu t appeared often enough to warrant attention.

In addition to identifying the psychological techniques medical personnel judge as important for recovery, it is also essential to determine which treatment options are acceptable, or perceived as valuable, to patients, primarily because patients' belief in, and acceptance of treatments they are receiving may have a powerful influence on the recovery process (Duda, Smart, & Tappe, 1989; Ievleva & Orlick, 1991).

The present study was designed to assess the opinions of physiotherapists who work in the management of sports injuries as to the characteristics of athletes who cope well with injury and rehabilitation and the value of psychological skills in rehabilitation. We also expanded the s tudy to gather the opinions of the most important people in the rehabilitation process, the patients. In this s tudy they were male professional basketball players. Access to top level professional sports men and women is difficult at best, and we had comaections to the National Basketball League. Thus, we could look only at male professional players, and that is a limitation of the study and a problem for generalization. The advantage of the s tudy is, however, tha t we did have access to professional players, a group (predominantly male) who are vastly underresearched.

We expected the results for physiotherapists to be similar to the findings of Wiese et al. (1991) and Gordon et al. {199I) in that willingness to listen, positive attitude, intrinsic motivation, and willingness to learn about the injury and rehabilitation techniques would be rated as the most important characteristics for injured athletes. We expected athletes would have a positive regard for psychological strategies in sport injury rehabilitation, with a preference for goal setting. But the order of the remaining preferences, and the degree to which they agree with physiotherapists, could not be predicted from the limited literature.

Method Part ic ipants Physiotherapists The participants {_n_ = 57) were wortdng in sport medicine clinics ill Melbourne. The sample consisted of 36 males and 21 females, the ages ranging from 26 years to 54 years (_M__ = 37.28 years, SD = 5.92). All were qualified physiotherapists. Overall, 39 of the 57 participants held postgraduate qualifications (three people had more than one postgraduate qualification). The breakdown of post graduate qualifications were: graduate diploma in manipulative physiotherapy (_O_ = 29), graduate diploma in sports physiotherapy (D_ = 4), graduate diploma in exercise for rehabilitation (_n_ = 3), graduate diploma in ergonomics (_n_ = 2), graduate diploma by research (_n_ = 1}, master 's in manipulative therapy (D_ = 1}, and Ph.D. (D_ = 1). The remaining 18 participants had completed bachelor degrees. The participants had an average of 14.2 years experience as physiotherapists and a mean of 12.8 years experience with athletic populations.

Professional athletes The participants ~ = 28) were professional basketball players from five teams in the Australian National Basketball League. The men ranged in age from 18 years

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to 38 years ~ = 26.96, S_DD = 5.41), had played professional basketball for an average of 7.61 years ~ = 4.75), and had suffered a self-reported average of 4.79

= 4.37) injuries each requiring physiotherapy over the past two years.

Measures Wiese et al. (1991) granted permission to reproduce the survey instrument used for their study. The survey underwent minor language changes to apply it to samples of Australian professional athletes and Australian physiotherapists.

The survey consisted of three sections, each requiring item ratings according to a 5-point Likert scale (e.g., not at all important = 1, very important = 5). First, physiotherapists and athletes were asked to "Rate the importance of the following characteristics or factors in distinguishing athletes who coped most successfully from those who coped least successfully with their injuries" (12 items; e.g., willingness to listen to physiotherapist, high self-esteem). The second section asked, "Rate the effectiveness of the following techniques or strategies for facilitating athletes' ability to psychologically cope with injury rehabilitation" (11 items; e.g., coach support of athletes, positive reinforcement by physiotherapist). The third section required physiotherapists and athletes to decide, "How important is knowledge about the following strategies for physiotherapists in dealing with injured athletes?" (12 items; e.g., teaching the use of mental imagery, encouraging positive thoughts). Each section also had a blank, or open, item for participants to complete if they felt some important characteristic had not been represented. Tile full questionnaire is available from the second author.

Procedure Surveys were posted to all 115 physiotherapists listed in the 1996 Melbourne Yellow Pages telephone directory as wortdng in sports medicine clinics or whose work predominantly involved the treatment of athletic injuries. A letter describing the s tudy and a consent form accompanied the survey, and participation was voluntary. A month after the initial survey was sent out, a follow up letter and survey were sent to physiotherapists that had not yet replied. Physiotherapists were asked to complete the survey and re turn it in the reply paid envelope provided.

Permission from the National Basketball League clubs was obtained to distribute the surveys to the players. In two cases, contact was made with the club physiotherapist who then distributed the survey to the players. In the other three instances, contact was made with a playing member of the team, who agreed to forward the surveys to the other team members. Sixty surveys in total were handed out to the basketball players. If the players wished to participate in the study, they were instructed to sign the consent form, fill out the survey, and re turn it in the reply paid envelope provided. Two weeks after the surveys were delivered, players were given a verbal reminder from the club contact to re turn the survey if they agreed to participate. One final reminder was given two weeks later.

Data Analysis Descriptive statistics (means and standard deviations) were calculated for each item for physiotherapists and professional athletes (presented in Tables 1-3). Independent t test for all items were conducted between physiotherapists and professional athletes. Because of the exploratory nature of this study (professional athletes have never been measured with these scales), no Bonferroni adjustments were made. Such adjustments would have dropped the alpha levels to a point

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Physiotherapists' and Male Professional Athletes' Views on PsVchological...

where the probability of a Type II would a lmost be a certainty, something to be avoided in researching new areas or new populations. The qualitative da ta were analyzed by simple content analysis of the open-ended responses.

R e s u l t s Physiotherapists returned 57 completed surveys for a response rate of 49.6%. TWenty-eight surveys were returned from the professional basketball players, for a response ra te of 47%. Given the anonymous mailing and the full schedules of professional basketball players these response rates are quite adequate. One physiotherapist survey was eliminated from the s tudy because only ha l f the questions were answered. Means and s tandard deviations for all the items on the three subscates for physiotherapists and athletes are presented in Tables 1, 2, and 3.

Pope, Tabachnick, and Keith-Spiegel (1987) and Tabachnick, Keith-Spiegel, and Pope (1991) set the criterion for a nearly universal behaviour a t agreement among 90% or more of the respondents. For the purposes of this study, ratings of 1 (not at all important/effective) and 2 (not important/effective) were combined as well as ratings of 4 (important/effective) and 5 (very important/effective). The nearly universally endorsed items (all in the 4-5 range) for physiotherapists and athletes are presented in Table 4. An "XT' in the columns under "Physiotherapists" and "Athletes" represents that those items were universally endorsed by that group.

TabacKnick et al. (1991) also described another category of items tha t they labelled "difficult judgements." An item tha t represents a difficult judgement is one where 25% or more of the respondents m a r k don't know or not sure. In this study, an i tem was classified as a difficult judgement ff 25% or more part icipants indicated neutra l for importance or efficacy of a characteristic or technique. The difficult judgements for physiotherapists and athletes are presented in Table 5 (an

Physiotherapists Athletes (n=56) (n=28)

Characteristic _M SD M S_.DD

High Academic Ability 2.60

High Sporting Ability 2.90

High Pain Tolerance 3.14

Emotional Maturity 3.65

Social Support (peers & parents) 3.88

High Self-esteem 4.04

Use of Goal Setting 4.11

Determination/Mental Toughness 4.28

Self-motivation 4.49

Willingness to Learn About Injury/Rehabilitation 4.51

Positive Attitude 4.54

Willingness to Listen to Physiotherapist 4.60

.73 2.52 .94

1.02 2.89 1.12

.79 3.59 1.01

.67 3.85 .82

.50 3.44 1.01

.78 4.30 .67

.70 4.00 .78

.84 4.52 .64

30 4.67 .62

.60 4.4B .51

.57 4.52 .57

.49 4.48 .51

Table 1: Physiotherapists' and athletes' average importance ratings of characteristics possessed by athletes who cope successfully witl] injury (1=not at all important, 5=very important).

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Physiotherapists Athletes (11=56) (11=28)

Techniques M SD M $_DD

Relaxation 3.19 .81 3.56 .64

Visualisation/Imagery 3.51 .93 3.52 .89

Encouraging Positive Thoughts 3.94 .68 3.67 .55

Variety in Rehab Exercises 4.19 .79 4.00 .55

Understanding of Injury Mechanism 4.26 .58 3.96 .71

Pos. Reinforcement by Physiotherapist 4.30 .60 4.07 .68

Focus on Short.Term Goals 4.32 .60 3.63 .56

Keeping Athlete Involved with Team 4.32 .63 4.48 .58

Aid Understanding of Rehab Strategy 4.34 .67 4.15 .66

Coach Support of Athlete 4.43 .59 4.44 .58

Realistic Time line to Full Recovery 4.49 .60 4.11 .80

Communication Skills of Physiotherapist 4.60 .53 4.1~ .66

Table 2: Ratings Of effectiveness Of strategies for facilitating athletes" abilities to cope psychologicafly with injury rehabilitation (t =not at aft effective, 5=rely effective).

Physiotherapists Athletes (_n=56) (11=28)

Strategies IVl SD M SD

Teaching Muscle Relaxation 3.34 .86 3.56 .70

Teaching Mental Imagery 3.55 .89 3.30 .70

Teaching Emotional Control 3.64 .80 3.33 .73

Teaching Concentration Skills 3.65 .88 3.19 .68

Enhancing Listening Skills 3.99 .77 3.59 .57

Reducing Depression 4.08 .63 3.59 .80

Enhancing Self-confidence 4.16 .59 3.59 .69

Encouraging Positive Thoughts 4.24 .54 3.74 .50

Understanding Stress/Anxiety 4.27 .57 3.76 .73

Understanding individual Motivation 4.35 .58 3.93 .62

Using Positive Communication Style 4.47 .60 4.11 .58

Setting Realistic Goals 4.62 .48 4.00 .55

Table 3-

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Important strategies for for physiotherapists when treating injured athletes (1=not at all effective 5=very effective).


Items from all Three Scales* Physiotherapists Athletes

Willingness to Listen to Physiotherapist (1)

Willingness to Learn About Injury/Rehab (1)

Self-Motivation (1)

Positive Attitude (1)

Aid Understanding of Injury Mechanism (2)

Communication Skills of Physiotherapist (2)

Realistic Timeline to Full Recovery (2)

Focus on Short-Term Goals (2)

Positive Reinforcement by Physiotherapist (2) Keeping Athlete involved with Team (2)

Coach Support of Athlete (2)

Using Positive Communication Style [3)

Determination/Mental Toughness (1)

Encouraging Positive Thoughts (2)

SeEing Realistic Goals (3)

Understanding Stress/Anxiety (3) Understanding individual Motivation (3)

X X

X X

X X

X X

X X X

X

X

X

X X X X

X

X X

X

X

* The number in parentheses after the item represents the scale where the item can be found. Note. An "X" represents that the item was endorsed 90% of the time, or more, by that group.

Table 4: Items nearly universafly endorsed (90% agreement) as important~effective by physiotherapists and athletes.

Items from all Three Scales* Physiotherapists Athletes

High Ability Level in Sport (1)

High Pain Tolerance Level (1)

High Academic Ability (I ]

Emotional Maturity (1) Relaxation Techniques (2)

Visualisation/Imagery (2]

Teaching Muscle Relaxation (3)

Teaching Mental imagery (3)

Teaching Emotional Control (3) Teaching Concentration Skills (3)

social Support (peers & parents) (1) Focus on Short-Term Goals (2)

Encouraging Positive Thoughts (2)

Reducing Depression (3) Understanding Stress/Anxiety (3)

Enhancing Self-Confidence (3)

Enhancing Listening Skills (3)

* The number in parentheses after the item represents the scale where the item can be found. Note. An "X" represents that the item was a difficult judgement for that group.

Table 5: Items with 25% or greater percentage of responses in the unsure or neutral catego~

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Physiotherapists' arid Male Professional Athletes' Views on Psychological...

"X" in the Columns represents tha t the group found tha t item a "difficult judgement").

The data for physiotherapists and athletes were compared and t tests and effect sizes were calculated. The n u m b e r in the parentheses after the t-test resul ts is Cohen's d for independent m e a n s (Cohen, 1988). In the first section of the survey, which considered the importance of certain characteristics in coping with injury, physiotherapists 'and athletes'opinions differed significantly on two characteristics. Firstly, physiotherapists thought social support from parents and peers to be more impor tan t than did athletes, t (82)= 2.10, p < .05 (.61). Secondly, athletes thought high pain tolerance level to be a more important characteristic for recovery than did physiotherapists, t (82)= - 2.40, p < .02 (.56). Although the effect sizes were of moderate magnitude, the opinions held by physiotherapists and athletes for both characteristics, were in the neutral range.

In the third section of the survey, significant differences of opinion were noted between athletes and physiotherapists on 9 ou t of the 12 items. Physiotherapists thought it more important t h a n athletes to u s e a positive communication style, t (82)=2.65, p<.02(.61). Physiotherapists also rated reducing depression as important, whereas athletes ra ted this constnact as neutral, t (82)= 2.79, p< .01 (.71). Similar results were obtained with physiotherapists rating higher t h a n athletes' for encouraging positive thoughts, t (82)= 3.99, p< .001(.93), for understanding stress/anxiety, t (82)= 3.53, p< .001 (.83), for imderstanding individual motivation, t (82)= 3.07, p< .005 (.72), and for enhancing self- confidence, t (82)= 3.87, p< .001 (.90). Both athletes and physiotherapists thought setting realistic goals was important. Physiotherapists, however, thought it significantly more important, t (82)= 5.00, p< .001 (1.23). Significant differences were also detected for enhancing listening skills, t (82)= 2.39, p< .02 (.56) and teaching concentration skills, t (82)= 2.42, p< .02 (.57) with physiotherapists rating these techniques as more important t h a n athletes, who rated them in the neutral range. All the effect sizes ranged f rom medium (.56) to very large (1.23) indicating tha t there were substant ia l differences between athletes and physiotherapists. Effect sizes are really the resul ts of interest, not p values, and statistical significance is not a measm'e of meaningful difference. See Andersen and Stoove (1998) for an a rgument that looking at effect sizes is far more informative t han relying on p values.

A word of caut ion is needed. The number of t tests performed means that it is possible some of the significant differences occurred by chance. If the alpha level were dropped to .01, there would still be several items where athletes and physiotherapists differed. Given the exploratory naklre of the s tudy (this is the first time professional athletes have been compared with physiotherapists on these issues), we did not consider this a lpha slippage a serious problem, b u t a caveat needed stating.

Open Items Physiotherapists Space was given after each section of the survey for participants to add in their own responses. For Section 1, there were 24 statements tha t were content analysed into five major categories. The additional characteris t ics/ techniques that emerged were the impor tance for the athlete to be compliant wi th physiotherapist instructions. Another factor tha t affects athletes coping with

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injury rehabilitation is whether or not the sport is the athletes' livelihood, for instance, the responses "Financial i.e., footballers paid" and " E ~ s i c motivation e.g., contract obligations/payment" fit in this livelihood category. The third category was personal characteristics of the physiotherapist (e.g., "Enthusiastic and knowledgeable physiotherapist"). Another important characteristic for athletes coping was the preinjury physical status of the athlete (e.g., "Recovered well from other injuries") and the final category involved external factors such as, "Existence of external aggravating factors (e.g., "work," 'Too much pressure from coach/ trainer").

Athletes The major category emerging for athletes from Section 1 was social support. For example, "support from coaching staff," "support from team mates," and "girl- friend" were mentioned. Also, time to recover was important to athletes, reflected in statements such as "Right amount of time for recovery" and '~Fime to heal." Physiotherapist qualities were also important to athletes, for example, "Good physio" and "Up-to date technique." A subset of this category was belief in the physiotherapist and treatment. The other characteristic mentioned by athletes was patience. Not enough data was generated from Sections 2 and 3 for physiotherapists or athletes to form any coherent themes.

Genes'a[ DiSCUSSiOn The results on physiotherapists' opinions of the psychological aspects of injury recovery are in general agreement with the Findings of Wiese et al. (1991). First, psychological components are recognised by physiotherapists as being important for injury recovery, with the majority of strategies having an average rating of "important." Second, physiotherapists and athletic trainers in both studies held similar opinions as to the importance of particular psychological characteristics, skills, and knowledge about skills. In common with Wiese et al. (1991), the two most important factors in injury rehabilitation according to physiotherapists were communication and motivation.

Physiotherapists graded, '%Villingness to listen to physiotherapist" as the most important characteristic possessed by athletes who cope successfully with their injuries. Again, in the second section, communication received high priority as "interpersonal communication skills of physiotherapist" was ranked the most important, and this was a universally held opinion for Australian physiotherapists in the sample, tn the responses to the third section, knowledge about using a positive and sincere communication style was ranked as the most important item. These findings fur ther support the emphasis placed upon this skill by physiotherapists.

Motivation and encouragement also seem to be significant issues for physiotherapists when treating injured athletes because positive attitude, intrinsic motivation, determination/mental toughness, and use of goal setting were thought to be adaptive characteristics for athletes coping with injury. Furthermore, focus on short- term goals and positive reinforcement by the physiotherapist were rated as effective techniques, and also, physiotherapists thought they should have knowledge regarding setting realistic goals, under- s tanding individual motivation, encouraging positive self-thoughts, and enhancing seK-confidence.

Athletes' generally regarded psychological components as important in injury

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rehabil i ta t ion and held similar opinions to physiotherapists concerning characteristics that benefit an individual's ability to cope with injury. For example, the seven most important characteristics for athletes were exactly the same as the physiotherapists top seven. The responses of athletes indicate their desire to take an active part in the rehabilitation process, The five most highly rated characteristics are concerned with individual participation in rehabilitation and understanding of the recovery process.

Another significant finding was that athletes believed possessing knowledge of a realistic time line to fftll recovery to be helpful in the healing process. This opinion also appeared in athletes' qualitative responses with comments such as, "Right amount of time for recovery." Considering these responses are from professional athletes, it may be that often they are not given realistic time frames to recover. There may be pressures to re turn to play too early, which could come from the coach, team, or the player himself. This added pressure could contribute to the s tress and anxiety that injured athletes generally experience (I_arson et al., 1996). Gordon et al. (1991) found that the pressure from the coach and fellow athletes to return quickly had a negative effect upon an athlete's performance during rehabilitation. They suggested that coaches should know more about sporting injuries and the methods involved in rehabilitation. Hence, it is important for athletes to be given adequate time to recover, and thus, this should be t aken into consideration when setting healing goals and also when communicating with the coach and club. This could be accomplished by a tripartite meeting of athlete, physiotherapist, and coach to discuss realistic time lines, recovery stages, and the rehabilitation process.

There is some inconsistency regarding athletes' attitudes to goal setting. The professional athletes thought goal setting was useful in coping with injury and wanted physiotherapists to have knowledge about setting realistic goals, yet they rated a focus on short-term goals substantially lower than physiotherapists. A purely speculative suggestion for this inconsistency may be that athletes are not aware that setting short- term goals is a basic part of the general goal setting process. Brewer et al. (1994), however, found athletes to hold favourable opinions of goal setting in the context of injury rehabilitation.

Both physiotherapists and athletes thought the least effective techniques for rehabilitation were visualisation and relaxation. These results are in agreement with athletic trainers in the Wiese et al. (1991) study. Furthermore, athletes and physiotherapists did not think they needed to have knowledge about relaxation and visualisation techniques. These attitudes have also been confirmed in a recent s tudy by I_arson et al. (1996), who found athletic trainers rarely used relaxation and mental imagery techniques and did not consider it important to have knowledge about these techniques when treating injured athletes. Larson et al. also found the most commonly reported psychological response by athletes to injury w a s that of stress/anxiety, a finding similar to Ford and Gordon (1997). Trainers in the Larson et al. s tudy did not think it important to reduce stress or anxiety, whereas Australian physiotherapists thought it was important to unders tand stress/anxiety in their patients.

There is an apparent inconsistency among physiotherapists in that they want to unders tand stress/anxiety but do not regard relaxation techniques as either effective in treatrnent, or having knowledge of them to be important. This could indicate a lack of understanding of the value of relaxation techniques, because

26


these techniques are fairly standard practice for psychologists in treating stress/anxiety (Benson, 1975). In addition, both the effectiveness of relaxation and visualisation techniques, and whether physiotherapists should be knowledgeable in these approaches, qualified as "unsure opinions" according to the criteria set for this study. Unsure or neutral responses may indicate physiotherapists' tack of familiarity, rather than genuine belief that relaxation and visualisation are ineffective.

Physiotherapists thought it important to reduce depression in athletes. Larson et al. (1996) found athletic trainers reported depression occurring frequently among injured athletes. Furthermore, Brewer et al. (1991) found depression to be the most common reason for physicians to refer an injured athlete to a psychologist. Brewer et al. (1995) also found evidence of psychological distress among physical therapy patients being treated at clinics specialising in sports medicine.

Treating stress/anxiety and depression are specifically in the domain of psychologists, and there may be areas where sport psychologists can contribute to the rehabilitation of injured athletes and the education of physiotherapists. In addition, Lynch (1988), who has had extensive experience in psychologically treating injured athletes, suggested the strategies that seem to be the most effective are those concerned with reducing stress, fear, and panic. It is unrealistic to expect physiotherapists to become expert in treating these conditions or to have the time and resources to address clinical psychological issues. Therefore, a useful service that sport psychologists could provide to physiotherapists is instruction in recognising these problems and setting up a process by which referrals can be made. Larson et al. (1996) advocated that a sport psychology referral network be set in place in sports medicine clinics, particularly because not all sport medicine teams have sport psychologists on staff.

The findings of this study are limited by the somewhat small samples and the use of only male professional basketball players. Future researchers might wish to expand the sample size to include physiotherapists across Australia, and attempt to gather data from female and male professional athletes from a variety of sports in order to have greater generalisability. Also, the physiotherapists in this study worked at sports medicine centres, but many had not received qualifications in "sports physiotherapy" specifically. Future researchers might want to compare general physiotherapists with those with sports physiotherapy training.

The results of the study, however, do make it possible to give some provisional recommendations to physiotherapists, athletes, and psychologists regarding treatment of sporting injuries. The major issues for physiotherapists in facilitating injury rehabilitation are communication, motivation, and encouragement. Psychologists can be useful in all three of these areas, particularly by providing training for physiotherapists to help facilitate communication with athletes. Wiese and Weiss (1987) have suggested that psychologists should train sports medicine personnel in communication skills. Psychologists could also train physiotherapists in motivational techniques, such as goal setting, or also provide motivation strategies directly to the athletes if appropriate.

The number of items representing unsure, or difficult, judgements, for physiotherapists and athletes suggests that both these groups, and especially athletes, do not have much exposure to psychological skills training. Physiotherapists have expressed feelings of limitations in dealing with the

27


psychological aspects of sporting injuries, and Gordon et al. (1991) found that 87% would like to have additional training in these areas. Gordon, Potter, and Ford (1998} have developed a psychoeducational curriculum for training individuals who are working with injured athletes, and their work should be consulted by those interested in injured athlete management. Such training and application could also be provided by sport psychologists in conference seminars and continuing education classes and could help physiotherapists (and psychologists) to better serve the athletes in their care.

Author Note Susan R. Francis, D e p ~ e n t of Psychology; Mark B. Andersen, School of Human Movement, Recreation and Performance and Centre for Rehabilitation, Recreation and Performance; Paul Maley, North Melbourne Giants.

We would like to thank Britton Brewer, Judy Van Raalte, and Angelo Mancuso for their helpful comments on an earlier draft of this paper.

Correspondence on this article should be sent to Mark B. Andersen, School of H u m a n Movement, Recreation and Performance, Victoria University, City Campus, P.O. Box 14428, MCMC, Melbourne 8001. Email may be sent to [mark. andersen@vu, edu.au].

R~ferences Andersen, M. B., & Stoove, M. A. (1998). The sanctity of p< .05 obfuscates good stuff: _A comment

on Kerr and Goss. Journa l of Applied Sport Psychology, 10: 168-173. Benson, H. {1975). The rela=mtion response. New York: William Morrow. Brewer, B. W., Jeffers, K. E., Petitpas, A. J., & Van Raalte, J. L. {1994). Perceptions of

psychological interventions in the context of sport injury rehabilitation. The Sport Psychologist, 8: 176-188.

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 spo t s medicine. Sports Medicine, Training, and Rehabilitation, 6: 139-t45.

Cohen, J. (1988). Statistical power analysis for the behavioural sciences (2rid ed.). Hillsdale, NJ: Erlbaum.

Danish, S. J. (1986). Psychological aspects in the care and treatment of athletic injuries. In P. F. Vinger & E. F. Hoerner (Eds.), Sports injuries: The unthwarted epidemic (pp. 345-353). Littteton, MA: PSG Publishing.

Duda, J. L., Smart, A. E., & Tappe, M. K. (1989). Predictors of adherence in the rehabilitation of athletic injuries: An application of personal investment theory. Journa l of Sport and Exercise Psychology, I I : 367-381.

Durso-Cupal, D. (1998). Psychological interventions in sport injury prevention and rehabilitation. Jou rna l of Applied Sport Psychology, i0:103-123.

Eldridge, W. D. (1983). The importance of psychotherapy for athletic-related orthopedic injuries among adults. Comprehensive Psyehiatry, 24:271-277.

Ford, I. W., & Gordon, S. (1993). Social support and athletic injury: The perspective of sport physiotherapists. Australian Journal of Science and Medicine in Sport, 25:17-25.

Ford, I. W., & Gordon, S. (1997). Perspectives of sport physiotherapists on the frequency and significance of psychological factors in professional practice: Implications for curriculum design in professional training. Australian Journal of Science and Medicine in Sport, 29: 34-40.

Ford, I. W., & Gordon, S. (1998). Perspectives of sport trainers and athletic therapists on the psychological content of their practice and training, Journa l of Sport Rehabilitation, 7: 79- 94.

Gordon, S., & Lindgren, S. (1990). Psycho-physical rehabilitation from a serious sport injury: Case study of an elite fast bowler. Australian Journal of Science and Medicine in Sport, 22: 71-76.

Gordon, S., Milios, D., & Grove, J. R. (1991). Psychological aspects of the recovery process from sport injury: The perspective of sport physiotherapists. Australian Journa l of Science and

28

Physiotherapists' and Male Professional Athletes' Views on Psychological.,.

Medicine in Sport, 23: 53-60. Gordon, S., Potter, M., & Ford, I. W. {1998). Toward a psyehoeducational curriculum for training

sport-injury personnel. Journal of Applied Sport Psychology, 10: 140-156. Ievteva, L., & Orliek, T. (1991). Mental links to enhanced healing: An exploratory study. The

Sport Psychologist, 5: 25-40. Larson, G. A., Starkey, C., & Zaichkowsky, L. D. (1996). Psychological aspects of athletic injuries

as perceived by athletic trainers. The Sport Psychologist, 10: 15-24. Lynch, G. P. (1988). Athletic injuries and the practicing sport psychologist: Practical guidelines

for assisting athletes. The Sport Psychologist, 2: 161-167. Pearson, L. & Jones, G. (1992). Emotional effects of sports injuries: Implications for

physiotherapists. Physiotherapy, 78: 762-770. Pedersen, P. (1986). The grief response and injury: A special challenge for athletes and athletic

trainers. Athletic Training, 21: 312-314. Pope, K, S., Tabaehnick, B. G., & Keith-Spieget, P. (1987). Ethics of practice: The beliefs and

behaviors of psychologists as therapists. American Psychologist, 42: 993-1006. Smith, A. M., Scott, S. G., & Wlese, D. M. (1990). The psychological effects of sports injuries.

Sports Medicine, 9: 352-369. Tabachnick, B. G., Keith-Spiegel, P., & Pope, K. S. (1991}. Ethics of teaching: Beliefs and

behaviors of psychologists as educators. American Psychologist, 46:506-515. Tuffey, S. (1991}. The role of athletic trainers in facilitating psychological recovery from athletic

injury. Athletic Training, 26: 346-351. Weiss, M. R., & Troxel, R. K. (1986). Psycholo~f of the injured athlete. Athlet ic Training, 2: 104-

109. Wiese, D. M., &Weiss, M. R. (1987). Psychological rehabilitation and physical injury: Implications

for the sport medicine team. The Sport Psychologist, 1: 318-330. Wiese, D. M., Weiss, M. R., & Yukelson. D. P. (1991). Sport psychology in the training room: A

survey of athletic trainers. The Sport Psychologist, 5: 15-24. Williams, J. M., & Roepke, N. (1993). Psychology of injury and injury rehabilitation. In R. N.

Singer, M. Murphey, & L. K. Termant (Eds.), Handbook of research on sport psychology {pp. 815-839). New York: Macmillan.

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physiotherapists' and male professional athletes' views on psychological skills for...

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