Yiaho IA

Avis sur

Dafotec Récupération De Données

Dépanneur informatique · Villeneuve-d'Ascq

Sport Injury-Related Growth : DOCTORAL THESIS
Sport Injury-Related Growth
Theory-to-Practice
Roy-Davis, Kylie
Award date:
2017
Awarding institution:
University of Roehampton
General rights
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners
and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.
• Users may download and print one copy of any publication from the public portal for the purpose of private study or research.
• You may not further distribute the material or use it for any profit-making activity or commercial gain
• You may freely distribute the URL identifying the publication in the public portal ?
Take down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately
and investigate your claim.
Download date: 20. avr.. 2025
Sport Injury-Related Growth:
Theory-to-Practice
Kylie Roy-Davis
A thesis submitted in partial fulfillment for the degree of PhD
Department of Life Sciences
University of Roehampton
2017
i
This thesis is dedicated to Adam.
ii
Declaration
This thesis is the author’s own work, and has not been previously submitted for an award
of this university or any other institution.
Signed:……………………………..
Date:………………………………..
STATEMENT 1
The content of the thesis is legally allowable under copyright legislation.
Signed:……………………………..
Date:………………………………..
STATEMENT 2
I hereby give consent for my thesis, if accepted, to be available for photocopying and for
interlibrary loan, and for the title and summary to be made available to outside
organizations.
Signed:……………………………..
Date:………………………………..
iii
Summary
This thesis explored the concept of sport injury-related growth (SIRG). Specifically, the
mechanisms through which growth occurs and how it may be promoted for injured
athletes. Study 1 used a grounded theory methodology to develop a context-specific
theory. Aligning with a Straussian approach, data was collected using semi-structured
interviews and analysed using open, axial, and selected coding. Findings revealed that the
mechanisms of (a) meta-cognition, (b) positive reappraisal, (c) positive emotions, and (d)
facilitative responses are what enable SIRG. These mechanisms are influenced by a
combination of internal (e.g., personality) and external (e.g., received social support)
factors. These factors enable injured athletes to alter their perception of their injury into
an opportunity for growth, and it is by drawing upon and mobilizing a variety of these
resources that athletes are able to experience SIRG. Dimensions of growth were
psychosocial, physiological, and behavioral. Although this study produced a theory that
explains the SIRG process, it does not propose specific techniques or therapies that
encourage the development of growth. To address this issue, Study 2 aimed to investigate
and identify evidence-based interventions that promote growth after experiencing
adversity. To achieve this aim, a systematic review was conducted on literature pertaining
to the promotion of growth for populations who have undergone a stressful experience
(e.g., medical illness). In total, 34 studies were located and obtained that met the
preplanned inclusion criteria. Within these 37 studies, three types of interventions were
identified: emotional processing, cognitive processing, and combined techniques. The
authors of the studies who successfully demonstrated the promotion of growth either
identified or suggested that growth occurs through the mechanisms of cognitive
restructuring and/or reappraisal. Other important considerations that were identified
through this review were the duration and timing of the intervention in relation to the
adverse event, and the importance of the intervention meeting the needs of the
participants. Although this study offers valuable insight into how growth may be more
successfully nurtured, the studies included within this review did not specifically focus
on promoting growth for injured athletes. Consequently, Study 3 sought to complement
this study by examining the practice-based experiential knowledge of sport psychologists
who have worked with injured athletes in an applied manner. In total, 10 sport
psychologists were purposively sampled and interviewed. Data was collected using a
semi-structured interview guide and analysed using content analysis. Findings revealed a
fluid development framework that consisted of 5 phases: (a) reactionary phase, (b)
preparation phase, (c) reflection phase, (d) application phase, and (e) monitoring phase.
Within each phase a set of corresponding strategies, skills, and tools were identified that
the sport psychologists would utilize to match the needs of the athletes. The sport
psychologists also identified a number of personal and environmental factors that either
promoted or hindered the development of SIRG. Altogether, this thesis supports and
extends research regarding growth and sport injury, as well as offering applied
practitioners useful information for promoting SIRG.
iv
Table of Contents
Page
Dedication……………………………………………………………………………….... i
Declaration……………………………………………………………………………….. ii
Summary………………………………………………………………………………….iii
Table of Contents…………………………………………………………………………iv
Publications and Presentations……………...……………………….……….…...... ……ix
Appendices………………………………………………………………………....……...x
Tables……………………………………………………………………………………..xi
Figures…………………………………………………………………………………... xii
Acknowledgements……………………………………………………………………...xiii
Chapter 1: Introduction…………………………………………………………………1
What is this Ph.D. about?.............................................................................................2
Background…………………………………………………………………………..2
Conducting research………………………………………………………………….4
Overview……………………………………………………………………….....….6
Chapter 2: Literature Review.........................................................................................11
Abstract ......................................................................................................................12
Introduction ................................................................................................................13
Responses to Sport Injury.....................................................................................13
Models and Theories of Sport Injury .............................................................14
v
Responses to Sport Injury Research.....................................................................22
Emotional Responses .....................................................................................13
Coping Strategies ...........................................................................................25
Growth Research ..................................................................................................27
Models and Theories of Growth.....................................................................29
Growth Research ............................................................................................33
Sport Injury and Growth.......................................................................................35
Summary and Recommendation for Future Research................................................39
Chapter 3: A Grounded Theory of Sport Injury-Related Growth .............................43
Abstract ......................................................................................................................44
Introduction ................................................................................................................45
Methods......................................................................................................................49
Philosophical Orientation and Methodology........................................................49
Participants...........................................................................................................50
Data Collection and Procedure.............................................................................51
Data Analysis .......................................................................................................53
Results........................................................................................................................56
Sport Injury...........................................................................................................57
Meta-Cognition and Positive Reappraisal............................................................58
Positive Emotions and Facilitative Responses.....................................................59
Internal Resources................................................................................................63
External Resources...............................................................................................65
vi
Sport Injury-Related Growth................................................................................69
Discussion ..................................................................................................................71
Chapter 4: Interventions to Promote Growth Following Adversity: A Systematic
Review of Evidence-Based Practice (Study 2)...............................................................78
Abstract ......................................................................................................................79
Introduction ................................................................................................................80
Methods......................................................................................................................82
Design...................................................................................................................82
Inclusion Criteria..................................................................................................82
Search Strategy.....................................................................................................83
Shifting of Research Papers .................................................................................84
Results........................................................................................................................86
Emotional Processing Interventions.....................................................................86
Cognitive Techniques Interventions...................................................................103
Combined Techniques Interventions..................................................................107
Qualitative Interventions....................................................................................109
Discussion ................................................................................................................112
Chapter 5: Practice-Based Evidence of Facilitating Sport Injury-Related Growth:
Phases and Strategies Recommended by Sport Psychologists...................................123
Abstract ....................................................................................................................124
Introduction ..............................................................................................................125
vii
Methods....................................................................................................................128
Design and Assumptions....................................................................................128
Sampling Procedure and Participants.................................................................128
Interview Guide..................................................................................................130
Data Analysis .....................................................................................................132
Results......................................................................................................................133
Reactionary Phase ..............................................................................................133
Preparation Phase ...............................................................................................138
Reflection Phase .................................................................................................141
Application Phase...............................................................................................144
Monitoring Phase ...............................................................................................149
Influential Factors of SIRG ................................................................................151
Athlete’s Personality ....................................................................................152
Team Environment/Culture..........................................................................154
Social Support Network ...............................................................................156
Athlete’s Free Time......................................................................................158
Discussion ................................................................................................................160
Chapter 6: General Discussion and Conclusions……………………………………168
Introduction ..............................................................................................................169
Summary of Studies ...........................................................................................169
Study 1: A Grounded Theory of Sport Injury-Related Growth..........................170
viii
Study 2: Evidence Based Interventions to Promote Growth
Following Adversity: A Systematic Review......................................................171
Study 3: Practice-Based Evidence of Facilitating Sport InjuryRelated Growth: Phases and Strategies Recommended by Sport
Psychologists......................................................................................................172
Synthesis of Results Across Studies……………………………………………….173
Theoretical and Empirical Impact of this Thesis......................................................175
Theoretical Impact..............................................................................................175
Empirical Impact ................................................................................................179
Practical Implications...............................................................................................181
Strengths and Limitations.........................................................................................187
Future Research Recommendations.........................................................................188
Overall Conclusions.................................................................................................190
References.......................................................................................................................192
Appendices......................................................................................................................227
ix
Publications and Presentations
Journal Publications
Roy-Davis, K., Wadey, R., & Evans, L. (2017). A grounded theory of sport injury-related
growth. Sport, Exercise, and Performance Psychology, 6(1), 35-52. DOI:
10.1037/spy0000080
Conference Presentations
Roy-Davis, K., Wadey, R.m & Evans, L. (2017). Practice-Based Evidence of Facilitating
Sport Injury-Related Growth: Phases and Strategies Recommended by Sport
Psychologists. Poster session to be presented at the 2017 Association for Applied
Sport Psychology (AASP) 32nd Annual Conference, Orlando, USA.
x
Appendices
Page
Appendix
A. Participant consent form- Study 1..................................................................228
B. Participant debrief form- Study 1 ..................................................................231
C. Participant information sheet- Study 1 ..........................................................214
D. Interview Guide- Study 1...............................................................................236
E. Participant consent form- Study 3..................................................................243
F. Participant debrief form- Study 3 ..................................................................246
G. Interview Guide- Study 3...............................................................................249
xi
Tables
Table 1. Qualitative Assessment for Quantitative Studies ................................................88
Table 2. Emotional Processing Interventions ....................................................................91
Table 3. Cognitive Interventions....................................................................................... 93
Table 4. Combined Interventions...................................................................................... 96
Table 5. Qualitative Interventions..................................................................................... 97
Table 6. Measures of Growth used in Interventions: Abbreviations and Full Titles.........98
Table 7. Sport Psychologist’s Overall Strategies and Skills............................................145
Table 8. Sport Psychologist’s Overall Tools ...................................................................147
xii
Figures
Figure 1. Wiese-Bjornstal, D., Smith, A., Shaffer, S., & Morrey, M. (1998).
An integrated model of response to sport injury: Psychological and
sociological dynamics. Journal of Applied Sport Psychology, 10, 46-68 .........................16
Figure 2. Brewer, B., Andersen, M, & Van Raalte, J. (2002). Psychological
aspects of sport injury rehabilitation: Toward a biopsychosocial approach. In
D. Mostofsky & L. Zaichkowsky (Eds.). Medical and psychological aspects of
sport and exercise, (pp. 44-54). Morgantown, West Virginia: Fitness
Information Technology ....................................................................................................19
Figure 3. Kubler-Ross, E. (2009). On death and dying: What the dying have to
teach doctors, nurses, clergy and their own families. London, United
Kingdom: Taylor & Francis...............................................................................................21
Figure 4. Tedeschi, R., & Calhoun, L. (1995). Trauma and transformation:
Growing in the aftermath of suffering. Thousand Oaks, CA: Sage Publications..............30
Figure 5. Roy-Davis, K., Wadey, R., & Evans, L. (2017). A grounded theory
of sport injury-related growth. Sport, Exercise, and Performance Psychology,
6(1), 35-52..........................................................................................................................56
Figure 6. Shifting of researcher papers..............................................................................85
Figure 7. Conceptual Model of the Development of Sport Injury-Related
Growth .......................................................................................................................................................135
xiii
Acknowledgments
First and foremost, I want to thank my supervisors, Dr. Ross Wadey and Dr. Lynne
Evans, as well as my Director of Studies, Dr. Ceri Diss for their continuous support and
encouragement during this thesis. I cannot express enough how much I appreciate your
time and attention. Thank you for giving me this wonderful opportunity. Particularly
Ross, thank you for your guidance and for being a truly wonderful supervisor.
A very special thank you to my family. Mom, you have always been my biggest
cheerleader and believed in me when I didn’t believe in myself. Grandma and Grandpa,
thank you for your enthusiasm, and I’m sorry that I’ve been away for so long. To the rest
of my family, thank you for your love and understanding.
Thank you to all my friends, both in the U.K. and U.S.A. You’re all amazing, beautiful
people and you’ve helped me so much whether you knew it or not. To my fellow PhD
candidates, thank you for the happy memories I’ll take with me. It was great sharing this
journey with you.
I would also like to thank all my participants. I truly appreciate that you gave me your
time and shared your stories. This thesis would not exist without you.
Lastly, thank you to Adam. You’re the best friend and husband I could ask for. You’re
my rock.
1
Chapter 1:
Introduction
2
What is this PhD about?
The aim of this Ph.D. was to better understand the sport injury experience,
particularly how sport injury may actually provide beneficial aspects, commonly referred
to as “growth”, for athletes who have sustained injury. More specifically, this programme
of research sought to provide practical information that may further assist individuals
who work with injured athletes in an applied manner. Through the use of qualitative
research and systematic review, this thesis explored the sport injury experience as well as
the promotion of growth for injured athletes. The purpose of the first study, A Grounded
Theory of Sport Injury-Related Growth, was to develop a context-specific theory
pertaining to the development of growth following a sport injury. The second study,
Interventions to Promote Growth Following Adversity: A Systematic Review of EvidenceBased Practice, used a systematic review methodology to explore interventions that have
been used to promote growth for traumatized populations. The final study, PracticeBased Evidence of Facilitating Sport Injury-Related Growth: Phases and Strategies
Recommended by Sport Psychologists, investigated the experiences and expertise of sport
psychologists who have worked with injured athletes in order to further comprehend the
issues surrounding growth cultivation in a practical setting. Collectively, these three
studies have helped to advance the knowledge of sport injury, in particular the ways in
which growth may be developed as a result of a sport-related injury.
Background
The topic of sport injury has long since been an interest of mine, however, I was
always drawn to the field of psychology. Fortunately, despite a lifetime of involvement in
3
sport and physical activity I never experienced a significant sport injury, yet I would
constantly see friends and teammates struggle through an injury they had sustained
through sport. I knew that I wanted to help them, but I did not know how. Although I
would often try to help alleviate the burden of their injury, I could see the toll their injury
was having on them, not just physically but mentally and emotionally as well.
In the days before I even began this Ph.D., when I was still trying to figure out
what a thesis was and what mine may look like I met with Dr. Ross Wadey. During this
meeting he told me about his idea for a programme of research that would begin with the
development of a theory related to sport injury-related growth. Although I was vaguely
familiar with the concept of post-traumatic growth, I had not yet seen this concept related
to sport injury. This quickly sparked a change in my perception of sport injury- the idea
that athletes may actually return to their sport better than they were before their injury.
This idea went beyond exciting me; it felt right to me and I could immediately see the
contribution this research could have for the field of sport injury.
Suddenly, I was seeing sport injuries differently. While it was, and is still, my
opinion that sport injury will never be a good thing- no one wants to be injured- but
maybe for those unlucky ones who do get injured, my research could help these athletes
be a little less unlucky. Maybe sport injuries did not have to be this terrible, debilitative
thing. Maybe sport injuries could become an experience that helps athletes. Rather than
muddling through their recovery, injured athletes could potentially be guided to
achievements they had never reached before or change in ways that will positively affect
them. This created not only a personal revelation, but also became the inspiration and
focus for my Ph.D.
4
Conducting Research
Although I knew that the general idea driving my thesis was exploring the
concept of growth following sport injury, specifically with the aim of creating a contextspecific theory, I needed to decide how this aim would be achieved. Immediately I knew
that this first research effort would be a qualitative nature, a methodology I had become
familiar with during my undergraduate and graduate studies, but had never personally
undertaken. From my time as a student before starting this Ph.D., I knew that research
could be of either a qualitative or qualitative nature, or, in some instances, a mixture of
the two. I had conducted quantitative research as a Masters student, and can appreciate
the satisfaction questionnaires and a numerical value can bring. However, as someone
who hesitates around numbers and gravitates towards stories, I knew that my real interest
was in qualitative research. While I was confident that I could rise to the personal
challenge a numbers-based study, I instinctively knew that I wanted more than that- I
wanted the story beyond the statistics. I wanted to discover and explore the feelings and
experiences of these athletes, and wholeheartedly embraced the qualitative approach.
Despite my tendency to reduce research methodology to its most basic elements
(i.e., quantitative research is numbers, qualitative research is words), this does not fully
encapsulate the qualitative research approach. Indeed, the term “qualitative research”
lacks a clear definition, and is often defined as simply being the counterpoint to
quantitative research (Martin, 2011). Qualitative research does, however, hold common
characteristics, such as its search for meanings, subjectivity, context, and reflexivity
(Sparkes & Smith, 2014). So while quantitative research is focused on measuring facts
and explaining the relationship between these facts in a technical manner, the goal of
5
qualitative research is to gain understanding of how people experience and make sense of
the world (Smith & Caddick, 2012). I knew that this was the research I wanted to conduct
and I began to familiarize myself with different qualitative approaches, namely the
grounded theory methodology, as I knew this would be the research methodology of my
first study.
What I was unaware of at this point, was the importance of determining my own
views of ontology and epistemology. A bit bewildered at first- wasn’t I studying
psychology, not philosophy? I soon realized the significance of these concepts and the
relationship between personal viewpoints and research design. So rather than rustling up
an interview guide and diving into date collection as I had initially imagined, I found
myself pondering on various philosophical ideals and reflecting on my own
interpretations of reality and knowledge. Eventually, and with much deliberation, I
decided my personal beliefs were those of a post-positivist with critical realism and
modified dualism/objectivism. To elaborate, critical realism refers to the idea that the
reality that humans perceive is influenced by unobservable events and it is only through
attempting to understand these events that we are able to comprehend the social world.
Modified dualism/objectivism refers to my belief that as a researcher, it is my duty to
make efforts to minimize any effect my presence may have on the research process. Upon
deciding these views, I could begin to plan and conduct my research accordingly.
Throughout this programme of study, as I progressed through my research and decided
on the ensuing steps to be taken, I would constantly question whether the research I was
designing and analyzing aligned with my personal beliefs. These beliefs have important
6
implications, as my personal assumptions influenced how I approached and conducted
the research within this thesis.
Overview of the Thesis
This dissertation consists of six chapters in total, and contains three original
studies. This introduction serves as the first chapter and is presented for the purpose of
providing clarity and to prime the reader for the forthcoming chapters. Following this
Introduction, Chapter II, Literature Review, is presented to provide a critical review and
synthesis of the current literature related to the areas of responses to sport injury, growth
research, and sport injury and growth. Specifically, the aims of this chapter are to (a)
provide information on the existent research pertaining to sport injury as well as the
models and theories of sport injury; (b) review the research related to the emotional
responses of athletes upon sustaining injury, and the reported coping strategies these
athletes subsequently employ; (c) present and explain the concept of growth following a
traumatic or stressful event, including descriptions and critical appraisals of models and
theories of growth, as well as describing and critically reviewing prominent growth
research; (d) draw together the concepts of sport injury and growth by explaining and
critically appraising research that has focused on this area; and (e) summarize the
information presented in this chapter and provide recommendations for future research,
before concluding with the aims and rationale for this programme of research.
Chapter III, A Grounded Theory of Sport Injury-Related Growth, reports results
from Study 1, which aimed to develop a context-specific theory of growth following a
sport injury by exploring the experiences of injured athletes who perceived a degree of
7
growth from their own injury. A grounded theory methodology was conducted, with 37
injured athletes taking part and providing a total of 70 interviews collected through the
use of semi-structured interviews. After each interview, the data was transcribed and
analyzed using a method of open, axial, and selective coding. Findings reveal that injured
athletes are able to experience the development of growth through the mechanisms of
metacognition, positive reappraisal, positive emotions, and facilitative responses. These
mechanisms are influenced by the presence of a combination of internal and external
factors, which if support the development of growth, will positively affect the athlete and
result in a perception of injury has holding inherent opportunities. This theory provides
greater insight into the injury experience, particularly the role and occurrence of growth
related to sport injury, illuminating why some athletes may be able to experience the
development of growth while others are not. However, this study did not provide
information on how this growth process may be encouraged in an applied setting, and
therefore the aim for the following study focused on delving into the topic of specific
interventions that may successfully promote growth.
Chapter IV, Interventions to Promote Growth Adversity: A Systematic Review of
Evidence-Based Practice, gives a description and the results from the second study of this
thesis. This study used a systematic review methodology to investigate the use of
interventions that have demonstrated success in promoting post-traumatic growth. As the
ultimate goal for this thesis is to provide information that will aid applied practitioners
working with injured athletes, the desired research question at the commencement of this
study was to focus on research conducted regarding post-traumatic growth and sport
injury. However, as this is a relatively new area of research and there is insufficient, if
8
any, existent literature that addresses this research question, the goal of this review
shifted to concentrate on any intervention-based research conducted with the goal of
fostering growth for a population that had experienced a stressful or traumatic event. In
total, 37 studies were identified that met the pre-determined inclusion criteria. These 37
interventions fell into 4 categories: (a) emotional processing- seeking to provide the
participant with a sense of closure, catharsis, or fulfillment; (b) cognitive strategieswhich attempt to bestow participants with the relevant tools to aid the post-traumatic
growth process; (c) combined technique- interventions that drew upon both emotional
and cognitive processing techniques; and (d) qualitative interventions- studies which used
interventions aimed at promoting growth but focused on gaining rich, in-depth
information gathered through interviews and observations. Among the studies that
successfully demonstrated the encouragement of growth, the researchers either identified
or suggested that these interventions were able to foster growth through the mechanisms
of cognitive restructuring and/or reappraisal. This review also identified that both the
duration of the intervention and the timing of the intervention implementation after the
traumatic event are important considerations. These findings illuminate certain methods
through which growth may be better encouraged yet these studies did not focus on
promoting growth for injured athletes. The need to further understand the process of
urging growth for injured athletes provided the rationale for the following study.
Chapter V, Practice-Based Evidence of Facilitating Sport Injury-Related Growth:
Phases and Strategies Recommended by Sport Psychologists, explains the procedure and
results of the final study in this programme of research. The goal of this study was to
gather information about the real-world experiences of sport psychologists who work
9
with injured athletes in a practical setting. In particular, this research sought to explore
any issues related to the promotion of growth for applied practitioner working with
injured athletes and investigate how these practitioners have been able to successfully
encourage growth for injured athletes. This study specifically decided to use sport
psychologists for participants, as these individuals were more likely to be familiar with
the concepts of post-traumatic growth and therefore provide richer, more in-depth data.
Ten sport psychologists were purposively selected for their expertise and experiential
knowledge and data was gathered through the use of semi-structured interviews. Analysis
of the data revealed that the sport psychologists were able to encourage growth by
effectively guiding the injured athlete through a fluid developmental framework. This
framework consists of five phases: (a) reactionary phase, (b) preparation phase, (c)
reflection phase, (d) application phase, and (e) monitoring phase. The sport psychologists
also reported using a variety of specific strategies, skills, and tools that would be
employed to match the current needs of the athletes. Finally, a number of personal and
environmental factors were identified that either promoted or hindered the development
of growth. These results offer useful information to applied practitioners and in this way
extend the previous research.
Chapter VI, General Discussion and Conclusions, is the final chapter and brings
this dissertation to a close by summarizing the three studies and discussing their
contribution to knowledge. After this review of the three original studies and their results,
this chapter concentrates of the theoretical and empirical impact, as well as the practical
implication of this research. Thereafter, the strengths and limitations of this thesis are
10
discussed and recommendations for avenues of future research are presented. Finally, the
central aspects of this programme of research are drawn together in an overall conclusion.
11
Chapter 2:
Literature Review
12
Abstract
The purpose of this chapter was to provide a critical review of the psychology of sport
injury literature, the concept of growth following adversity, and recent research that has
aimed to integrate these two bodies of literature Specifically, this reviews describes a
model, theories, and research related to the psychological response to sport injury,
namely the integrated model of response to sport injury developed by Wiese-Bjornstal,
Smith, Shaffer, and Morrey (1998). It also synthesizes the literature related to models,
theories and research on post-traumatic growth. Lastly, it draws these two concepts
together in the context of growth following a sport injury. The review considers both
conceptual and methodological issues across the bodies of literature. The chapter
concludes with a summary and recommendations for areas of future research.
13
Introduction
The purpose of this chapter is to provide a critical review of the research related
to the concepts of sport injury and growth following adversity as a basis for the rationale
for this programme of research. The chapter has been divided into four sections:
Responses to Sport Injury, Growth Following Adversity, Sport Injury and Growth, and
Summary. The first section, Response to Sport Injury, will synthesize the research into
athletes’ psychological responses to sport injury. The second section, Growth Following
Adversity, will explore the literature related to benefits associated with undergoing a
traumatic or stressful event across a variety of populations and types of stressful events.
The third section, Sport Injury and Growth, will examine the research relating to the
benefits derived from experiencing a sport-based injury. This review has been separated
so as to introduce the reader first to the topic of Responses to Sport Injury, as this is
considered the primary concept of this sport psychology-based thesis. However, this
thesis is also concerned with the field of post-traumatic growth and therefore the
following section, Growth Following Adversity, helps facilitate knowledge translation
between other fields of research and sport psychology by contextualizing growth
following sport injury and the large body of research exploring growth following
adversity. Finally, to draw these two fields together, the third section, Sport Injury and
Growth, provides a contextualized understanding of growth within the context of sport
injury. The fourth and final section will provide a summary of the chapter and
recommendations for future research.
Responses to Sport Injury
Although research into the psychology of sport injury dates back to the 1960’s,
14
the majority of it has been conducted over the last 20 years. Findings in this field have
indicated that athletes who have sustained injury undergo cognitive, emotional, and
behavioural changes, the majority of which have been considered unpleasant in nature
(Evans, Mitchell, & Jones, 2006). Indeed, injury has been viewed as a largely negative
experience characterized by heightened levels of depression, frustration, and helplessness
(e.g., Evans & Hardy, 1995; Leddy, Lambert, & Ogles, 1994). Where positive effects of
injury were reported they emerged serendipitously (e.g., Bianco, Malo, & Orlick, 1999;
Ford & Gordon, 1999; Hurley, Moran, & Guerin, 2007; Podlog & Eklund, 2006; San
Jose, 2003; Tracey, 2003). However, in recent years, researchers have begun to
investigate positive consequences related to sport injury (e.g., Udry, Gould, Bridges, &
Beck, 1997) encouraging a shift to a more inclusive view of the injury experience
(Wadey, Evans, Evans, & Mitchell, 2011), wherein both negative and positive
experiences are considered. Unfortunately, to date these studies have been somewhat
solitary in nature, and not provided a focused, systematic approach to this important line
of enquiry.
A more inclusive view of the research to date, suggests that injured athletes report
both negative (i.e., anxiety) and positive (i.e., increased resilience) responses, suggesting
that injury may not be an inherently a negative experience as originally conceived.
Indeed, contrary to the prevailing belief that injury is a largely negative experience, in
recent years research has highlighted the ways in which athletes are able to benefit from
their injury and even experience a degree of growth as a result of it (e.g., Galli & Vealey,
2008; Podlog & Eklund, 2006; Tracey, 2011; Udry et al., 1997; Wadey et al., 2011;
Wadey, Evans, Hanton, & Neil, 2012).
15
Models and Theories of Sport Injury
As the field of sport injury research has grown, researchers have endeavored to
provide explanations of the injury experience and the underlying processes through the
development and application of various models and theories. These models and theories
include the integrated model of response to sport injury (Wiese-Bjornstal, Smith, Shaffer,
& Morrey, 1998), biopsychosocial model of sport injury rehabilitation (Brewer, 2003),
stage-based grief response models (Kubler-Ross, 2009), self-determination theory (Deci
& Ryan, 2011), cognitive-motivational relational theory of emotion (Lazarus, 2000), selfefficacy theory (Bandura, 1994), reversal theory (Apter, 1989), personal investment
theory (Maehr, & Braskamp, 1986), and protection motivation theory (Rogers, &
Prentice-Dunn, 1997). The first three of these - the integrated model of response to sport
injury, the biopsychosocial model of sport injury rehabilitation, and the stage-based grief
response - will now be discussed, as these are typically the most adopted within the sport
injury research. Indeed, the factors and processes identified by these models, and theory,
have also been identified in research pertaining to post-traumatic growth; in this way,
these models and theory show promise for making connections between the fields of
sport injury and growth following adversity. Of particular importance to this programme
of research, is the integrated model of response to sport injury (Wiese-Bjornstal et al.,
1998), as this model has received the most empirical support to date (Wadey & evans,
2011), and has served as the foundation for this thesis.
Although each model and theory has specific strengths, the model that has
received the most attention in the literature is the integrated model of response to sport
injury (Wiese-Bjornstal et al., 1998). According to this model (see Figure 1), a
16
Stress Response
Sport
Injury
History of
Stressors
Coping
Resources
Intervention
Personal Factors Situational Factors
Cognitive Appraisal
Goal adjustment
Rate of perceived
recovery
Self-perceptions
Beliefs and attributes
Sense of loss or relief
Cognitive coping
Injury
History
Severity
Type
Perceived cause
Recovery status
Individual Differences
Psychological
Personality
Self-perception
Self-motivation
Motivational orientation
Pain tolerance
Athletic identity
Coping skills
Psychological skills
History of stressors
Mood states
Demographic
Gender
Age
Ethnicity
Socioeconomic status
Prior sport experience
Physical
Ergogenic aids
Physical health status
Disordered eating
Sport
Type
Level of competition
Time in season
Playing status
Practice vs. game
Scholarship status
Social
Teammate influences
Coach influences
Family dynamics
Sports medicine team
influences
Social support provision
Sport ethic/philosophy
Environmental
Rehabilitation
environment
Accessibility to
rehabilitation
Behavioural Response
Adherence to rehabilitation
Use of PST strategies
Use/disuse of social support
Risk taking behaviours
Effort and intensity
Malingering
Behavioural coping
Emotional Response
Fear of unknown
Tension, anger, depression
Frustration, boredom
Positive attitude/outlook
Grief
Emotional coping
Recovery
Outcomes
-Psychosocial
-Physical
Figure 1. Wiese-Bjornstal Integrated Model of Response to Sport Injury
17
combination of pre-injury and post-injury variables influence an athlete’s
responses to injury and their ensuing recovery outcome. Factors such as personality (e.g.,
perfectionism), history of stressors (e.g., previous injury/injuries), coping resources (e.g.,
psychological skills), and interventions (e.g., stress management) comprise the pre-injury
variables. Post-injury variables include personal factors (e.g., severity of injury) and
situational factors (e.g., time of competitive season). These factors influence an athlete’s
cognitive appraisal of their injury and rehabilitation, and their emotional and behavioural
responses, and recovery outcome. For example, a runner who has incurred his second
knee injury three months before the start of the competitive season, experienced this
injury previously (i.e., personal factor/history of stressors), but has sufficient time before
the season begins (i.e., situational factors), might have a positive attitude about making a
full recovery (i.e., cognitive and emotional response). This in turn could affect his
adherence to his rehabilitation programme (i.e., behavioural response), resulting in a
shorter, more successful recovery process and returning to competition at an equivalent,
or even higher level of functioning than previously (i.e., recovery outcome). In this
instance, an athlete may exhibit signs of growth resulting the injury. This model, although
well-developed and widely used, however, does not provide a detailed explanation of the
mechanisms through which athletes may experience the full range of possible recovery
outcomes.
More recently, Brewer (2003) developed the biopsychosocial model (see Figure
2), which integrates the frameworks of existing models of sport injury rehabilitation (e.g.,
Wiese-Bjornstal et al., 1998) with more general models of health outcomes (e.g., Cohen
& Rodriguez, 1995). The biopsychosocial model is comprised of seven dimensions:
18
injury characteristics, sociodemographic factors, biological factors, social and contextual
factors, intermediate biopsychological outcomes, and sport injury rehabilitation
outcomes. In this model, injury characteristics refers to the nature of the injury (e.g., type,
location, severity, history), which together with the individual’s sociodemographic
factors (e.g., age, gender, race/ethnicity, and socioeconomic status) will influence the
biological (e.g., immune functioning), psychological (e.g., personality), and
social/contextual (e.g., life stress) factors. These three factors will subsequently affect the
intermediate biopsychological outcomes, such as range of motion, strength, pain, and
recovery rate. Finally, these intermediate outcomes will influence the rehabilitation
outcomes, for example, functional performance, quality of life post-injury, treatment
satisfaction, and desire and readiness to return to sport. Within this model, psychological
factors play a unique, central role, having a direct bidirectional relationship with
biological and socio-contextual factors, and the resulting intermediate and final recovery
outcomes. While this model provides a holistic framework that helps to explain the
process of sport injury rehabilitation, it does not offer an explanation of the relationships
between the specific psychological variables.
Prior to models that were specifically developed in a sport injury context, sport
injury research often drew upon the stage-based grief model developed by Kubler-Ross
(2009). This model (see Figure 3), which was derived to explain the emotional
experiences of the terminally ill, postulates that grieving individuals will experience five
stages: shock and denial, anger, bargaining, depression, and acceptance. Shock and
denial, the first stage, is characterised by an individual’s failure to accept their current
situation. This denial is reported to function as a buffer, affording the individual time to
19
Psychological
Factors
- Personality
- Affect
- Behaviour
Injury Characteristics
- Type
- Location
- Antecedents
(history)
- Cause
- Severity
Socio-demographic
Characteristics
- Age
- Gender
- Race/ethnicity
- Socio-economic
status
Biological Factors
- Endocrine
- Respiration
- Metabolism
- Tissue repair
- Sleep
- Nutrition
- Circulation
- Immune functioning
- Neurochemistry
Social/contextual
Factors
- Social network
- Life stress
- Situational
characteristics
- Rehabilitation
environment
Biopsychological Intermediate
Outcomes
- Range of motion
- Strength
- Endurance
- Joint elasticity
- Rate of recovery
- Pain
Sport Injury Rehabilitation Outcomes
- Functional performance
- Quality of life
- Satisfaction of treatment
- Readiness to return to sport
Figure 2. Biopsychosocial Model.
20
begin mobilising psychological defences. The second stage is characterised by anger,
which is directed either externally (e.g., coach) or internally (i.e., self) and is fuelled by a
sense of betrayal. Next, a stage of bargaining, is marked by the individual attempting to
find a sense of resolution by offering pledges; this part of the process is typically kept
secret or only shared with those the individual deems trustworthy. A period of depression
follows, marked by symptoms such as social withdrawal, hopelessness, and
unproductiveness. This depressive stage appears to be the longest period within the grief
process and is considered to serve as a tool to facilitate acceptance of the impending loss.
In the final stage of acceptance, they acknowledge their loss and its consequences. While
reaching this stage does not denote a sense of happiness, it does signify the completion of
the individual’s progression through the grieving process. Although developed for a
different population, sport injury researchers have argued the applicability of grief to an
athletic population, positing that athletes’ exhibit a comparable grief response upon
sustaining injury (Evans & Hardy, 1995). This grief is postulated to be due to the
significant personal loss that occurs as the result of the injury and the interruption it
causes to an athlete’s investment in their training and sport participation (Brewer, 1999;
Van Der Poel, J., & Nel, P., 2011). However, a number of researchers have questioned
the relevance of this model to the sports injury process, not least because of the
impermanent nature of most injuries (Rose & Jevne, 1993; Udry et al., 1998).
The strengths of the integrated model of sport injury response and the
biopsychosial model are that they were developed for sport injury and so are contextual
to this field of research (e.g., Brewer et al., 2002; Wiese-Bjornstal et al., 1998). Likewise,
the Kubler-Ross stage-based model of grief provides insight into the process that injured
21
Figure 3, Kubler-Ross Stages of Grief Model
athletes may face, particularly when the potential for loss if great and their identity as an
athlete is threatened. Although these models, alongside others not discussed within this
literature review, have aided our knowledge and understanding of specific concepts in an
injury context, they are limited in describing and explaining certain phenomena. These
limitations include firstly, a failure to define, delimit, and describe specific recovery
outcomes, which is essential for elucidating the recovery process and associated
outcomes. Also, across these models and theories is a failure to explain the mechanisms
for attaining certain recovery outcomes. For example, are there different processes for
different recovery outcomes? It is important to ascertain these mechanisms to guide
future research and theory development. Finally, the models described above were not
Time
Process
Denial
Anger
Depression
Bargaining
Acceptance
22
designed to direct interventions. Indeed, models need to bridge the gap between theory
and practice. For example, what interventions should practitioners use to help foster
desirable, and prevent undesirable, recovery outcomes?
Responses to Sport Injury Research
Upon sustaining an injury, athletes are likely to experience a range of emotional,
cognitive, and behavioural responses (Evan, Mitchell, & Jones, 2006). As discussed in
the previous section, a number of models regarding the response to and rehabilitation
from sport injury have been proposed in the sport injury literature. The model that has
received the most attention in the response to sport injury research is the integrated model
of response to sport injury developed by Wiese-Bjornstal et al. (1998). Researchers have
focused on various aspects described in the model including: cognitive appraisal (e.g.,
Albinson & Petrie, 2003; Chung, 2012; Daly, Brewer, Van-Raalte, Petitpas, & Sklar,
1995; Ruddock-Hudson, O’Halloran, & Murphy, 2012; Weiss & Ebbeck, 1996), social
support (e.g., Abgarov, Jeffrey-Tosoni, Baker, & Fraser-Thomas, 2012; Mitchell, 2011;
Rees, Mitchell, Evans, & Hardy, 2010; Rees, Smith, & Sparkes, 2003), psychological
skills (e.g., Hare, Evans, & Carlow, 2008; Nordin-Bates et al., 2011; Wesch et al., 2012),
adherence to rehabilitation (e.g., Marshall, Donovan-Hall, & Ryall, 2012), interventions
(e.g., Rock & Jones, 2010), recovery outcomes (e.g., Brewer, 2010), and a number of
personal (e.g., athletic identity; Brewer, Cornelius, & Van Raalte, 2010) and situational
factors (e.g., timing of injury; Gayman & Crossman, 2003). As it is beyond the scope of
this review to examine the research pertaining to each of these variables, the following
sections will provide a critical discussion of injured athletes’ emotional responses and
coping attempts, as these concepts are germane to this thesis and are prominently featured
23
in both the literature regarding sport injury responses as well as the literature regarding
post-traumatic growth.
Emotional responses. The initial period following injury occurrence is typically
characterized by negative feelings, such as frustration, anger, and depression (e.g.,
Clement, Arvinen-Barrow, & Fetty, 2015). For example, Mainwaring et al.’s (2004)
reported a significant spike in depression, confusion, and total mood disturbance in
athletes immediately after injury occurrence; emotions that subsided three weeks after
injury, as the athletes began to cope with their situation. To better understand the
reactions related to sport injury, Udry et al. (1998) interviewed 21 elite skiers about their
responses after sustaining season-ending injuries. In total, 136 psychological reactions
were identified and categorized into four dimensions: injury-relevant information
processing-awareness (e.g., questioning), emotional upheaval/reactive behaviour (e.g.,
emotional agitation), positive outlook/coping attempts (e.g., good attitude/optimism) and
other (e.g., ambivalence). These results further highlight the temporal nature of
psychological reactions to injury, as athletes demonstrated a need to first process their
injury-relevant information before responding emotionally. However, the aim of this
study was not to determine the temporal sequence of psychological reactions, but to
investigate the range of responses that occur. This concept supports, and extends, the
findings of Quackenbush and Crossman (1994) who surveyed 25 injured athletes and
identified 48 emotional reactions related to the injury experience. Of these 48 reported
emotions, 36 were positive (e.g., hopeful) and 12 were negative (e.g., frustrated), and
likewise displayed a temporal element, with negative emotions decreasing over time and
positive emotions increasing.
24
Subsequent studies further suggest that athletes’ emotions are likely to shift and
become more positive as they progress through their recovery (e.g., Madrigal & Gill,
2014). However, injury onset is generally found to be associated with the experience of
numerous negative emotions such as fear, anger, or depression (Faris, 1985).
Rehabilitation is typically characterized as a period that includes discouragement,
frustration, and isolation, while return to sport is associated with emotions such as
impatience, anxiety, anticipation, and increased confidence (e.g., Bianco, 2001; Granito,
2001; Johnston & Carroll, 1998). In Tracey’s (2003) exploration of college athletes’
recovery from moderate to severe injuries, results showed that emotions fluctuated in the
time after injury, characterized by feelings of loss, lowered self-esteem, anger, and
frustration. Over time, however, athletes’ view of their injury began to evolve and injury
was instead perceived as a challenge and was approached with a positive attitude.
Ultimately, these athletes acknowledged that their injury and rehabilitation was a process
that facilitated greater self-understanding (e.g., inner strength) and appreciation (e.g., not
taking health for granted).
Ruddock-Hudson et al., (2014) investigated the emotional reactions of Australian
League Football players and found that the severity of the injury appears to moderate
athletes’ emotional reactions, with minor and severe and/or long-term injuries showing
distinct emotional variations. Minor injuries seem to present little concern or limitations
for athletes and so are responded to more positively and optimistically. Conversely, longterm injuries, such as knee reconstructions, invoke negative emotional responses and are
viewed as more challenging. Social support is another factor that moderates emotional
responses to sport injury, however, this effect diminishes with minor injuries.
25
Coping strategies. Sport injury is an experience associated with a high degree of
strain, leading researchers to focus on the coping strategies used by injured athletes
during injury onset, rehabilitation, and return to sport (e.g., Evans, Wadey, Hanton, &
Mitchell, 2012). Coping is defined as the “constantly changing cognitive and behavioural
efforts to manage specific external and/or internal demands that are appraised as taxing or
exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141). Just as
athletes experience a range of emotional responses as a result of a sport injury, they draw
upon a variety of coping strategies, specifically, emotion- or problem- focused. Emotionfocused coping strategies aim to manage the negative emotions associated with the
stressor (e.g., emotional disclosure). Problem-focused coping strategies concentrate on
tackling the stressful situation (e.g., planning). More recently, researchers have explored
the use of avoidant coping (e.g, Allen, Greenlees, & Jones, 2011; Carson & Polman,
2010), which refers to strategies used to avoid the situation through distraction (e.g.,
cognitive distancing) or social diversion (e.g., walking away). In this way, avoidance
coping strategies may facilitate control over short-term emotional states and has been
observed to be a strategy regularly used by athletes to deal with acute stress during sport
participation (Nicholls, Holt, Polman, & Bloomfield, 2006). However, avoidant coping is
generally associated with a number of psychological and physiological outcomes and is
suggested to be maladaptive long term (e.g., Kim & Duda, 2003). Other research on
coping skills related to sports injury reveal that athletes seek to gather information
regarding their rehabilitation to gain a better understanding on the route to recovery
(Carson & Polman, 2008), a form of problem-focused coping. Instances of emotionfocused coping strategies throughout the sport injury process (e.g., Udry et al., 1998;
26
Wadey et al., 2012b) include venting of emotions, seeking emotional social support,
positive self-talk, and reframing negative thoughts and emotions.
The possession and employment of coping skills appear to be shaped in part by
instances of past adversity (Bejar & Butryn, 2016). Being exposed to stressful events
previously may enable athlete to feel better prepared to face stressors, such as sport
injury. Athletes exhibit high degrees of perseverance through their participation in sport
and it is speculated that this determined approach helps athletes to cope with their injury.
In Albinson and Petrie’s (2003) examination in cognitive appraisals, stress, and coping
after sports injury, cognitive appraisals were found to be related to the coping strategies
used by injured athletes. Specifically, athletes’ primary and secondary appraisals of their
injury related to their coping strategies, with athletes who scored higher in mood
disturbance during this period demonstrating higher occurrences of avoidance coping
techniques. Findings from this study suggest that the first week post-injury may be a
crucial time-point for athletes’ appraisals, as this appraisal will influence athletes’ coping
strategies throughout the remainder of their recovery. For example, athletes that utilized
avoidant coping techniques at the seven-day mark after injury onset also exhibited less
cognitive active coping (i.e., attempts to manage appraisal of stressful event) during
subsequent assessments. This suggests that helping injured athletes to manage their
cognitive appraisals will also influence their engagement in behaviour aimed at dealing
with their injury and its affects.
Johnston and Caroll (2000) also found a temporal element, as their results showed
that coping varied as a function of stage in rehabilitation. It was also revealed that the use
of coping strategies declined over the course of rehabilitation, showing that rather than
27
shifting coping strategies, athletes’ use of coping declined overall as they progressed
through recovery. Furthermore, coping appeared to be a stable characteristic of
individuals, with no clear situational-specific coping strategy emerged from the data.
However, results did demonstrate that participants preferred informational and emotional
support in the middle and towards the end of their rehabilitation rather than at the
beginning. This may be due to the athletes in their study being less receptive and
regarding these types of support to be unnecessary during injury onset to deal with the
intense emotions that characterize it.
Growth Research
Historically, both research and anecdotal evidence has postulated how personal
gain can be derived from experiences of overcoming adversity (Joseph & Linley, 2004).
However, it has not been until recently that growth following adversity has been studied
with empirical and theoretical rigor (e.g., Calhoun & Tedeschi, 2006; Carver, 1998;
Heffernon, Grealy, & Mutrie, 2009; Joseph & Linley, 2008; Weiss & Berger, 2010).
Growth, defined as the perceived positive change that elevates a person to a higher level
of functioning after enduring a stressful or distressing event (e.g., Kampman, Heffernon,
Wilson, & Beale, 2015), can be personal (e.g., greater appreciation), psychological (e.g.,
increased confidence), social (e.g., strengthened relationships), and/or behavioural (e.g.,
improved coping skills) (e.g., Heffernon et al., 2009). Proposed mechanisms that support,
or hinder, the development of growth include deliberate rumination, meaning-making,
and social support (Tedeschi & Calhoun, 2004).
Growth may also be explained through the prism of mindsets (Dweck, 2006;
2007; 2012). According to Dweck, individuals lie on a spectrum between either a fixed
28
mindset or a growth mindset. Those who lie closer to the end of fixed mindsets believe
that each person has a finit