Journal of Sport Rehabilitation, 2015, 24, 189-197

http://dx.doi.org/10.1123/jsr.2013-0148
2015 Human Kinetics, Inc.

ORIGINAL RESEARCH REPORT

Athletes Use of Mental Skills During Sport

Injury Rehabilitation
Monna Arvinen-Barrow, Damien Clement, Jennifer J. Hamson-Utley, Rebecca A. Zakrajsek,
Sae-Mi Lee, Cindra Kamphoff, Taru Lintunen, Brian Hemmings, and Scott B. Martin
Context: Existing theoretical frameworks and empirical research support the applicability and usefulness of
integrating mental skills throughout sport injury rehabilitation. Objective: To determine what, if any, mental skills
athletes use during injury rehabilitation, and by who these skills were taught. Cross-cultural differences were
also examined. Design: Cross-sectional design. Setting: College athletes from 5 universities in the United States
and a mixture of collegiate, professional, and recreational club athletes from the United Kingdom and Finland
were recruited for this study. Participants: A total of 1283 athletes from the United States, United Kingdom, and
Finland, who participated in diverse sports at varying competitive levels took part in this study. Main Outcome
Measures: As part of a larger study on athletes expectations of injury rehabilitation, participants were asked a
series of open-ended and closed-ended questions concerning their use of mental skills during injury rehabilitation. Results: Over half (64.0%) of the sample reported previous experience with athletic training, while 27.0%
indicated that they used mental skills during injury rehabilitation. The top 3 mental skills reported were goal
setting, positive self-talk/positive thoughts, and imagery. Of those athletes that used mental skills, 71.6% indicated
that they felt mental skills helped them to rehabilitate faster. A greater proportion of athletes from the United
States (33.4%) reported that they used mental skills during rehabilitation compared with athletes from the United
Kingdom (23.4%) and Finland (20.3%). A small portion (27.6%) of the participants indicated that their sports
medicine professional had taught them how to use mental skills; only 3% were taught mental skills by a sport
psychologist. Conclusions: The low number of athletes who reported using mental skills during rehabilitation is
discouraging, but not surprising given research findings that mental skills are underutilized by injured athletes in
the 3 countries examined. More effort should be focused on educating and training athletes, coaches, and sports
medicine professionals on the effectiveness of mental training in the injury rehabilitation context.
Keywords: injured athletes, psychological interventions, survey design, cross-cultural
Research across the world has shown that mental
skills (ie, strategies used to trigger and sustain ideal
performance)1 can be helpful to athletes in the process
of achieving optimal athletic performance.2 More specifically, mental skills such as imagery,3 goal setting,4
Arvinen-Barrow is with the Dept of Kinesiology Integrative
Health Care & Performance Unit, University of WisconsinMilwaukee, Milwaukee, WI. Clement and Lee are with the
Dept of Sport Sciences, West Virginia University, Morgantown,
WV. Hamson-Utley is with the University of St Augustine for
Health Sciences, St Augustine, FL. Zakrajsek is with the Dept
of Kinesiology, Recreation, and Sport Studies, University
of Tennessee, Knoxville, TN. Kamphoff is with the Dept of
Human Performance, Minnesota State University, Mankato,
Mankato, MN. Lintunen is with the Dept of Sport Sciences,
University of Jyvskyl, Jyvskyl, Finland. Hemmings is with
the School of Sport, Health and Applied Science, St Marys University, London, UK. Martin is with the College of Education,
University of North Texas, Denton, TX. Address author correspondence to Monna Arvinen-Barrow at arvinenb@uwm.edu.

self-talk,5 and relaxation techniques6 have all been

documented as useful in facilitating, maintaining, and
improving athletic performance. In accordance with these
findings, the integrated model of psychological response
to sport injury and rehabilitation7 asserts that mental
skills are beneficial during sport injury rehabilitation.
This model posits that personal and situational factors
combine to influence athletes cognitive appraisal of their
injury situation and, depending on their assessment (ie,
thoughts about being injured), they exhibit emotional (ie,
feelings about being injured) and behavioral (ie, actions
and reactions to being injured) responses, both of which
may influence their subsequent cognitive appraisals. The
same process (cognitions affecting emotions, and emotions affecting behaviors) can also occur in the opposite
direction. According to the model, the use of mental skills
is deemed important during the sport injury process in
a number of ways: (1) as a mediating factor influencing
injury occurrence, (2) as a personal factor influencing
cognitive appraisals, and (3) as a behavioral response
potentially influencing both the cognitive appraisals and
emotional response to the injury situation.

189

190Arvinen-Barrow et al

Existing empirical evidence suggests that the

application of mental skills during rehabilitation supports this model.811 Sports medicine professionals
(SMPs), such as athletic trainers and physiotherapists,
use a range of mental skills with athletes during rehabilitation,913 and research indicates that goal setting
is the most popular technique used by both athletic
trainers and physiotherapists, regardless of the cultural
context.913 Research conducted in the United States
indicates that SMPs attitudes toward the effectiveness of mental skills vary, depending upon their level
of formal training with cognitive skills application.14
Hamson-Utley et al found that athletic trainers held
more positive attitudes toward the usefulness of mental
skills than physiotherapists.14 Although studies demonstrate that adopting mental skills during rehabilitation is warranted and welcomed by the SMPs, there is
limited research on athletes actual accounts of its use.
Moreover, previous investigations on the performance
context indicate varying cross-cultural differences.15,16
Thus, further investigation is required to determine if
these cultural influences dictate the application of such
skills in a sport injury rehabilitation context.
In addition to the sparse research available on the
prevalence of athletes use of mental skills during rehabilitation, there is limited information on which sports
professionals are best positioned to assist athletes to use
mental skills during sport injury rehabilitation. Ideally,
injured athletes should have access to a sports medicine
team that includes a credentialed sport psychology professional,17,18 however, most athletes and SMPs typically
have limited access to sport psychology services.19,20 As
a result, other professionals, such as athletic trainers and
physiotherapists, are often implementing mental skills
during rehabilitation. Whether SMPs or other allied health
professionals are teaching mental skills to athletes during
rehabilitation warrants further research.
To address these gaps in the literature, we attempted
to preliminarily determine: (1) what, if any, mental skills
athletes use during injury rehabilitation; (2) if there were
any possible cross-cultural differences in athletes use of
mental skills during injury rehabilitation; and (3) who
teaches mental skills to athletes during rehabilitation.

Methods
Research Design and Setting
A cross-sectional research design was used to sample
participants from both the United States and Europe. The
US-based participants were collegiate athletes who were
recruited from 5 universities across the country. The European athletes were a mixture of collegiate, professional,
and recreational club athletes from the West and East
Midlands regions of the United Kingdom and Finland.

Participants
A total of 1283 athletes (62.4% male; 36.0% female; 1.6%
did not identify their sex) participated in the study. Age
ranges spread across the following categories (1.6% did
not specify their age): 12 to 17 (n = 67; 5.2%); 18 to 21
(n = 754; 58.8%); 22 to 25 (n = 234; 18.2%); 26 to 35 (n
= 101; 7.9%); 36+ (n = 107; 8.3%). Of the sample, 699
(54.5%) were classified as US athletes and 584 (45.5%)
were classified as European athletes (332 from the United
Kingdom and 252 from Finland; for more details on the
participant demographics, see Table 1). The vast majority
(752, or 58.6%) identified themselves as student-athletes,
with a smaller number (135, or 10.5%) indicating that
they had a college/university degree or other qualifications (30.9% nonresponse). Participants described their
highest level of competition as (1) collegiate/university
(705, or 54.9%); (2) recreational or not competing at
all (240, or 18.7%); (3) national (166, or 12.9%); (4) at
either county, regional, or state level (74, or 5.8%); (5)
international (38, or 3.0%); (6) professional (24, or 1.9%);
or (7) no indication (36, or 2.8%). The 3 most cited sports
were American football (216, or 16.8%), soccer (211, or
16.4%), and track and field (161, or 12.5%). A total of 373
(29.1%) reported having a past history of acute injuries,
128 (10.0%) indicated that they experienced chronic
injuries, and 501 (39.0%) had suffered both acute and
chronic injuries, whereas 281 (21.9%) reported having
no history of injuries. Of the participants, 821 (64.0%)
indicated that they had prior experience working with
SMPs, whereas 406 (31.6%) indicated that they had no
prior experience working with SMPs (4.4% nonresponse).

Table 1 Participants Age Range and Sex by Country

Age, y
1217
1821
2225
2635
36+
Total

United States
Male
Female
n
%
n
%
1
0.2
0
0.0
319 71.7
221 88.0
113 25.4
28 11.2
11
2.5
2
0.8
0
0.0
0
0.0
444 55.6
251 54.3

United Kingdom
Male
Female
n
%
n
%
2
0.9
0
0.0
90 42.7
55 53.4
23 10.9
7
6.8
22 10.4
15 14.6
74 35.1
26 25.2
211 26.4
103 22.3

Finland
Male
n
%
48 33.3
26 18.1
33 22.9
32 22.2
5
3.5
144 18.0

JSR Vol. 24, No. 2, 2015

Female
n
%
16 14.8
43 39.8
29 26.9
18 16.7
2
1.9
108 23.4

Total
Male
n
%
51
6.4
435 54.4
169 21.2
65
8.1
79
9.9
799 62.4

Female
n
%
16
3.5
319 69.0
64 13.9
35
7.6
28
6.1
462 36.0

Mental Skills in Sport Injury Rehabilitation 191

Measure
As part of a larger study on athletes expectations of
injury rehabilitation,21,22 participants were asked a series
of questions regarding their use of mental skills during
injury rehabilitation. These inquiries contained both
open-ended and closed-ended questions. More specifically, the first question participants were asked relative
to their use of mental skills in injury rehabilitation was
a closed-ended question: Have you ever used mental
skills as part of your sport rehabilitation? Question 2, an
open-ended question, allowed participants to list up to 3
mental skills they had used during their injury rehabilitation. Question 3, a closed-ended question, was: Did the
athletic trainer(s) teach you how to use the skills? The
fourth question, a follow-up to the previous question,
was open-ended: If no, who did? The final question
was closed-ended: Do you believe that the use of mental
skills helped you to rehabilitate faster?
The survey items were modified for the UK and Finnish sample to take into account cultural differences. For
the UK survey, the term, athletic trainer, was changed to
physiotherapist to reflect the differences in professional
titles used in these different cultural contexts. In Finland,
the original questions were translated into Finnish following a commonly employed back-translation procedure23,24
used in cross-cultural research:
1. The original questions were translated from English to Finnish by an independent sport psychology
researcher who is fluent in both languages. At this
stage, the term, athletic trainer, was also changed
and translated to physiotherapist to reflect the
differences in professional titles used in different
cultural contexts.
2. The Finnish translated version was then translated
back into English independent of the original questions by a sport psychology professional who is
fluent in both languages but was not involved in the
initial translations.
3. The differences in the content and meanings between
the back-translated and the original questions were
then identified.
4. Due to the simplicity of the questions, no items
displaying discrepancy in either content or meaning
were identified.

Procedure
After institutional review board approval and before
administration of the surveys, all of the participants
were given a cover letter informing them of the purpose
of the study. The surveys were administered in a range
of ways, depending on the country in which the data
were collected. Participants at the US and UK universities received the questionnaires in person, either before
or after practices or classes. Some of the athletes in the
United Kingdom received the survey via SurveyMonkey

(Palo Alto, CA) through the national governing body

member mailing list. In Finland, surveys were administered in person to a convenient sample of both nonuniversity competitive athletes (club athletes) and university
athletes studying sport-related courses. In the cases of
participants under 18 years of age, parental consent was
also obtained. However, due to both the diversity of the
sample size and the diversity in data collection methods,
we were not able to calculate an overall response rate for
the study. Following completion of the questionnaires,
which took approximately 15 minutes, the participants
were thanked for their participation.

Statistical Analyses
Descriptive statistical analyses (ie, percentages and frequencies) were calculated for the closed-ended questions.
For the open-ended questions, multiple response sets were
created and then frequencies were calculated. Finally, a
chi-square analysis was conducted (with both sex and
country as a categorical level variable) to determine if
significant cultural differences existed when using mental
skills during injury rehabilitation. The qualitative openended answers were coded based on the commonly-used
categorization of mental skills (eg, imagery, goal setting,
self-talk, relaxation techniques).

Results
Of the 1283 participants, 346 (27.0%) indicated that
they had applied mental skills during injury rehabilitation, whereas 880 (68.6%) stated that they had not used
mental skills during rehabilitation (4.4% nonresponse).
Among those who reported using mental skills, the top 4
mental skills used were (1) goal setting (162, or 46.8%),
(2) positive self-talk/positive thoughts (115, or 33.2%),
(3) imagery (110, or 31.8%), and (4) relaxation (84, or
24.3%). Table 2 displays the athletes use of specific
mental skills by country. Of the 346 athletes who used
mental skills, 249 (72.0%) indicated that the use of
mental skills helped them to rehabilitate faster, whereas
48 (13.8%) felt that using mental skills did not facilitate
the speed of their injury recovery (14.2% chose not to
answer this question).
A significant difference (2 = 20.08, df = 2, P < .001)
was obtained based on the athletes country (see Table
3). That is to say, a greater proportion of athletes from
the United States (33.4%) reported that they used mental
skills during rehabilitation compared with the proportion
of athletes from the United Kingdom (23.4%) and Finland
(20.3%). No significant difference (2 = 0.378, df = 2, P
> .05) was found between the percentage of use of mental
skills by males and females during injury rehabilitation.
Of the participants who reported using mental skills
as part of their sport injury rehabilitation, 96 (27.7%)
indicated that their SMPs (ie, athletic trainer, physiotherapist or equivalent) had taught them how to apply mental

JSR Vol. 24, No. 2, 2015

192Arvinen-Barrow et al

Table 2 Specific Mental Skills Used During Rehabilitation

Mental skill
Goal setting
Positive self-talk/positive thoughts
Imagery
Relaxation
Other

United States
(n = 222)
n
%
115
51.8
88
39.6
70
31.5
57
25.7
15
6.8

United Kingdom
(n = 74)
n
%
24
32.4
21
28.4
22
29.7
6
8.1
2
2.7

Finland
(n = 50)
n
%
23
46.0
6
12.0
18
36.0
21
42.0
1
2.0

Total
(N = 346)
n
%
162
46.8
115
33.2
110
31.8
84
24.3
18
5.2

Table 3 Use of Mental Skills During Sport Injury Rehabilitation by Country (N = 1226)
United States
(n = 664)
n
%
222
33.4
442
66.6

Use or nonuse
Use mental skills during injury rehabilitation
Do not use mental skills during injury rehabilitation

United Kingdom
(n = 316)
n
%
74
23.4
242
76.6

Finland
(n = 246)
n
%
50
20.3
196
79.4

Note: Due to missing variables, the number of participants in each country is different than as presented in the text.

skills. Other sources included a coach (52, or 15.0%), the

athlete themselves (28, or 8.1%), the athletes family (26,
or 7.5%), or a sport psychologist (10, or 2.9%). There
was a 38.7% nonresponse rate.

Discussion
The primary purpose of this study was to determine what,
if any, mental skills athletes use during injury rehabilitation. Results indicated that 27.0% of athletes surveyed
reported using mental skills during injury rehabilitation.
Given that the use of mental skills in sport performance
has been supported by research for a long time,25 and that
these same skills are frequently being recommended by
SMPs for use in the rehabilitation setting,26,27 overall the
low number of athletes who reported using mental skills
during injury rehabilitation is a discouraging revelation.
According to Arvinen-Barrow and Walker,28 mental skills
are commonly underutilized during injury rehabilitation.
This may happen because athletes, and those who work
with them, are often unable to see a clear transfer of mental
skills from performance enhancement to sport injury
rehabilitation due to their limited knowledge on how to
use these mental skills when recovering from injury. Of
the athletes who did report using mental skills during
rehabilitation (n = 346, or 27.0%), goal setting (46.8%),
positive self-talk (33.2%), imagery (31.8%), and relaxation
techniques (24.3%) were listed as the 4 main strategies
employed. This is not surprising, because these skills are
among the most commonly used mental skills in sport,29
with goal setting being the most widely used by athletes
overall.30 Frequent use of goal setting is also supported by
studies conducted with SMPs. One study on SMPs attitudes about the effectiveness of mental skills used within
injury rehabilitation indicates that goal setting is perceived
as the most effective skill.14 Furthermore, results from 4

additional studies912 indicate that when working with

injured athletes, setting short-term goals appears to be the
second-most used technique by SMPs overall (second to
creating variability in rehabilitation exercises).
However, research remains unclear on the use,
perceptions, and effectiveness of self-talk and imagery
during injury rehabilitation. Hamson-Utley and colleagues14 reported that among SMPs, use of self-talk
and imagery was perceived as less effective than goal
setting in sport injury rehabilitation. Nevertheless, other
studies912 that explored the views and experiences of
SMPs who use mental skills show that, along with setting
goals, encouraging positive self-talk appears to be one
of the most advocated mental skills by SMPs, whereas
the use of imagery is among the 3 least-used mental
skills that SMPs employ during sport injury rehabilitation. Estepps31 research on National Collegiate Athletic
Association (NCAA) division I athletic trainers provided further insight into the use of mental skills during
rehabilitation, in that they reported using goal setting,
communication, and time management more often than
self-talk, relaxation, or imagery when working with
injured athletes during rehabilitation.
Of the athletes in the current study who had reported
using mental skills during rehabilitation, 72.0% believed
that the use of such skills influenced the speed of their
recovery and that the mental skills had a positive impact
on their injury recovery. Research on the effects of
mental skills in improving performance may influence
athletes perceptions or beliefs that such skills will likely
be beneficial during their injury rehabilitation. In addition, research that highlights the mindbody connection
suggests that patients who believe in and commit to their
therapy perceive it as much more effective.32 Since only
27.0% reported that they used these tools during their
rehabilitation, further understanding of why mental

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Mental Skills in Sport Injury Rehabilitation 193

skills are underutilized during rehabilitation warrants

further investigation.
A secondary purpose of the current study was to
investigate whether possible cross-cultural differences
existed in athletes use of mental skills during injury
rehabilitation. Results indicated a significant difference
in mental skill use, as US athletes (33.4%) used mental
skills more within injury rehabilitation contexts compared
with their UK (23.4%) and Finnish (20.3%) counterparts.
It is likely that this difference may be attributed to (1)
athletes receptiveness toward sport psychology, (2) possible cultural differences that exist in sporting cultures
among the countries represented in this analysis, and
(3) athletes exposure to athletic training services in the
United States.
Athletes exposure to sport psychology may vary
from one country to another due to how the services are
governed and structured, which is likely to influence
the availability of licensed, certified, or registered sport
psychology professionals. In the United States, 2 main
professional organizations promote and govern sport
psychology consultants (Association for Applied Sport
Psychology [AASP]33 and the American Psychological Association, Division 4734), whereas in the United
Kingdom, the sport psychology profession is primarily
governed by the British Psychological Society35 and the
Health and Care Professions Council,36 and also to an
extent, by the British Association of Sport and Exercise
Sciences.37 In both the United States and United Kingdom, clear educational pathways to the sport psychology
profession exist. Several universities in both countries
offer specific degrees that lead to a career path in sport
psychology. In Finland, on the other hand, the Finnish
Sport Psychology Association38 represents the profession and, only very recently, the Finnish Psychological
Association39 explicitly began to govern sport psychology
certification. Regarding Finnish universities, only 1 in the
country specifically offers a masters level degree in sport
psychology. Given the differences noted above, and the
lack of publicly accessible registers of sport psychologists
from each country, it is impossible to speculate the availability of sport psychology services to athletes within
each country. However, based on the current available
data, the number of AASP Certified Consultants available to athletes in the United States is 331.33 None of the
UK-based organizations provide explicit lists of sport
and exercise psychologists, so therefore, no comparable
data from the United Kingdom is obtainable. The Finnish
Psychological Association cites the number of certified
sport and exercise psychologists as 12.39 Despite the lack
of verifiable data, it seems likely that there are cultural
differences among these countries in terms of access to
sport psychology services.
Another factor that may explain cultural differences affecting the use of mental skills in rehabilitation
is the athletes own attitudes toward sport psychology
in general. Previous research that has investigated athletes attitudes toward the use of sport psychology has
also highlighted clear cultural differences. For example,

in a study investigating athletes attitudes toward sport

psychology consultants, it was found that overall, elite
Irish athletes appeared to hold positive attitudes toward
sport psychologists and were receptive in seeking sport
psychology help.40 In a similar study with athletes from
the United States, United Kingdom, and Germany, it was
found that US-based athletes were more likely to view
sport psychology in a negative light than their UK and
German counterparts.41 Previous studies4044 also indicate
that differences in attitudes toward sport psychology may
exist as a result of sex, sport type, and level of competition. Thus, it is possible that cultural differences found
in this study are the result of multiple factors, rather than
just geographical location or national culture.
Another component that may play a role in explaining the cultural differences found in the current study is
the way in which sports are structured in each country.
The majority of the athletes from the United States who
participated in this study were collegiate-level studentathletes. In the United States, 28.3% of the athletic
departments across 120 universities currently offer sport
psychology services to their athletes,45 and of those that
were included in this study, the majority (4 schools out
of 5) routinely offered sport psychology services to
their athletes. Therefore, it is likely that the US athletes
in the current study had potentially higher than average
exposure to sport psychology services. In addition, all
NCAA universities in the United States employ certified
athletic trainers to work with their student-athletes.46 As
part of their educational training, these certified athletic
trainers are required to have competencies in psychosocial aspects of injuries and rehabilitation.47 As a result of
these requirements for certification, athletic trainers often
implement mental skills training with college athletes
for preventing injuries and facilitating recovery.48 Conversely, physiotherapists educational training does not
explicitly require formal education or practice regarding
the psychosocial aspect of injuries. However, not all certified athletic trainers and physiotherapists working in the
field today received training under the current educational
competencies (since they may have received their education before the issuing of the new competency requirements), and this may influence the use and perception
of the effectiveness of mental skills in rehabilitation.17
Thus, to provide athletes with holistic care during the
injury rehabilitation process, and to ensure both physical
and psychological aspects of injuries are addressed as
required, further professional relationships and referral
networks between different professionals (particularly for
those SMPs with limited sport psychology training and
expertise) should be advocated and developed.
In the United Kingdom and Finland, the structure
of competitive sports is more private or voluntary clubfocused, and the hope of becoming an elite athlete is not
linked to the university structure as it is in the United
States. It is also common that sport psychology professionals and physiotherapists work independently outside
of a private or voluntary club. Although the majority of
the UK and Finnish sample were mainly collegiate- or

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194Arvinen-Barrow et al

university-aged athletes, due to the structure of sports

in these countries, it is likely that their access to a sport
psychology professional, or a SMP with training in sport
psychology,49 was more limited than the US sample.
Therefore, it is possible that athletes from the United
States are exposed to mental skills because of their close
proximity to professionals who are formally trained in
sport psychology.
Given the limited use of mental skills by professionals despite their proven effectiveness in the sport injury
rehabilitation context,26,28,50 it is important to understand
which professionals use mental skills to help injured
athletes. Hence, the third purpose of this study was to
determine which professionals have been teaching mental
skills to athletes during injury rehabilitation. Results
revealed that nearly 28% of injured athletes in this study
reported learning mental skills from SMPs; however,
of those, the vast majority were US-based athletes. In
addition, athletes reported learning mental skills from
coaches (15.0%), themselves (ie, self-taught; 8.1%), and
family members (7.5%) during their injury rehabilitation.
Ranked last are sport psychologists (~3.0%), who played
an additional role in teaching injured athletes mental skills
during injury rehabilitation.
The above findings are not surprising. While many
believe that sport psychologists are the best professionals to introduce and thus educate athletes on applying
mental skills during rehabilitation, it is known that very
few SMPs have access to sport psychology professionals during sport injury rehabilitation.912,51 Therefore,
the role of addressing psychological aspects of injuries
often falls on the SMPs shoulders.52,53 Moreover, SMPs
regularly work with athletes, and as such are uniquely
positioned to address both physical and psychological
aspects of recovery.28 Until sport psychologists become
a more common, yet distinct part of a sports team, SMPs
will continue to be responsible for the holistic care of
athletes, rehabilitating their mind and body.54 Current
medical rehabilitation research highlights the influence
of the mind over the body.55 Not only are SMPs very
aware of the mental side of injury, but this has also been
demonstrated by several theories as evidenced through
several studies.9,10,14,52 Today, this research informs many
evidence-based medical practices, including those with
injured athletes.54
Consistent with previous literature, the current
findings indicate that athletes underutilize mental
skills during injury rehabilitation, however, those who
do use these skills find them helpful. As such, it may
be imperative to regularly advocate the use of mental
skills to all athletes. In the United States, SMPs are the
most commonly-used professionals for this purpose.
Since it is commonplace for athletes, particularly
those at the elite level, to use mental skills to enhance
performance, the role of SMPs may not be so much
to teach new mental performance skills, but to show
athletes how to apply mental skills once they have
been injured. In other words, it may be that one of the
roles of SMPs in their pursuit to provide the best care

possible is to connect the dots for injured athletes,

showing them how their performance-related mental
skills can be applied to their rehabilitation from injury,
which is often a foreign or challenging environment
for most athletes.56
Similar to the performance enhancement context,
skills like goal setting, positive self-talk, and imagery
have been shown to be instrumental throughout the 3
phases of the injury recovery process.57 Research shows
that SMPs are often confident in using goal setting and
communication,52,58 and that their education likely has
an influence on what skills they choose to employ. The
professional preparation for most, if not all, of the allied
health care professionals includes traditional education
on writing patient notes, or SOAP (subjective, objective,
assessment, and plan) notes, in which the P represents
the plan for patient care. Hence, SMPs regularly use goal
setting strategies in the delivery of their rehabilitation
services and are likely comfortable teaching these skills
to their patients. Some of these SMPs may have been
formally trained to use imagery or self-talk, whereas
others, particularly those representing the generations
that graduated before the implementation of psychosocial educational competencies, are reluctant to use
these skills with injured athletes due to conceptual
misunderstandings related to how such psychosocial
skills may work in practical settings.52 Given that there
is a lack of research on how to best implement psychological skills into rehabilitation,59 it is important for
practitioners to ensure that they are advocating skills
that (a) are within their own personal competencies, (b)
athletes feel comfortable with, and (c) are meeting the
needs of the athletes at a given phase of their rehabilitation.57 The literature also suggests that practitioners
should identify their athletes psychological needs (ie,
stress and anxiety) and then select 1 or 2 mental skills
or techniques based on their ability, comfort, and prior
success.60
Despite a number of meaningful findings, the study
was not without its limitations. More specifically, the
results of the current study should not be generalized to
all athletes in the United States, United Kingdom, and
Finland, or with athletes at other competitive levels.
First, the differences in the structure, level of sports, and
the varying age groups who participate in sports within
the 3 countries could have impacted the results obtained
in this study. Second, the different environments (eg,
before or after practice or in a classroom setting) in
which the data were collected, in addition to the different methods used (online versus in person), could have
influenced the quality of data collected, thereby also
influencing the results obtained. Third, the differential
access to athletic trainers/physiotherapists and the
surveys failure to inquire about participants access to
these SMPs could possibly have influenced the findings
in the current study. Fourth, the large nonresponse rate
may potentially indicate a lack of interest in reporting
the use of mental skills or potential nonuse. Finally, a
lack of knowledge and exposure to sport psychology

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Mental Skills in Sport Injury Rehabilitation 195

and mental skills could have influenced participants

responses with regard to their use of mental skills in
the injury rehabilitation context.
Despite these limitations, this study provides
a meaningful assessment of athletes use of mental
skills in the rehabilitation context. However, additional
research is needed to further understand athletes use
of mental skills in injury rehabilitation. For example,
although the survey included open-ended questions, a
qualitative approach could be used to gain an in-depth
understanding of why athletes use or do not use mental
skills in injury rehabilitation. In addition, a standardized
psychometrically-sound instrument could be developed
and used to determine athletes use of mental skills in
injury rehabilitation.

Conclusions
In conclusion, only 27.0% of the athletes in the sample
reported that they used mental skills during their injury
rehabilitation, and only ~3.0% had learned mental skills
from a sport psychologist. Given these findings, the
authors believe that more effort is needed to educate
athletes, coaches, and injury treatment professionals
about the beneficial effects of mental skills, and how
they could be incorporated into rehabilitation programs.
Sport psychology professionals can play a significant
role in education and treatment of athletes. Practical
ways in which mental techniques can be integrated
into rehabilitation should be examined and tested in the
field. Unfortunately, there appears to be limited access
to sport psychology services at this time. Additionally,
since athletic trainers and physiotherapists are in a unique
position to teach mental skills to athletes during injury
rehabilitation, it becomes even more imperative that these
professionals receive training on the basic principles of
sport psychology and how best to implement mental skills
to injured athletes.

References
1. Williams JM, Krane V. Psychological characteristics of
peak performance. In: Williams JM, ed. Applied Sport
Psychology: Personal Growth to Peak Performance. 4th
ed. Mountain View, CA: Mayfield; 2001.
2. Hardy L, Jones G, Gould D. Understanding Psychological Preparation for Sport: Theory and Practice of Elite
Performers. Chichester, UK: John Wiley & Sons; 1996.
3. Arvinen-Barrow M, Weigand DA, Thomas S, Hemmings
B, Walley M. Elite and novice athletes imagery use in open
and closed sports. J Appl Sport Psychol. 2007;19:93104.
doi:10.1080/10413200601102912
4. Weinberg RS, Harmison RJ, Rosenkranz R, Hookim S.
Goal setting. In: Taylor J, Wilson GS, eds. Applying Sport
Psychology: Four Perspectives. Champaign, IL: Human
Kinetics; 2005:101116.
5. Theodorakis Y, Weinberg R, Natsis P, Douma I, Kazakas
P. The effects of motivational versus instructional self-talk

on improving motor performance. The Sport Psychol.

2000;14:253272.
6. Greenspan MJ, Feltz DL. Psychological interventions
with athletes in competitive situations: a review. The Sport
Psychol. 1989;3(3):219236.
7. Wiese-Bjornstal DM, Smith AM, Shaffer SM, Morrey MA.
An integrated model of response to sport injury: psychological and sociological dynamics. J Appl Sport Psychol.
1998;10:4669. doi:10.1080/10413209808406377
8. Hare R, Evans L, Callow N. Imagery use during rehabilitation from injury: a case study of an elite athlete. The Sport
Psychol. 2008;22(4):405422.
9. Clement D, Granquist MD, Arvinen-Barrow M. Psychosocial aspects of athletic injuries as perceived by athletic
trainers. J Athl Train. 2013;48(4):512521. PubMed
doi:10.4085/1062-6050-48.3.21
10. Arvinen-Barrow M, Hemmings B, Weigand DA, Becker
CA, Booth L. Views of chartered physiotherapists on the
psychological content of their practice: a national followup survey in the UK. J Sport Rehabil. 2007;16:111121.
PubMed
11. Hemmings B, Povey L. Views of chartered physiotherapists on the psychological content of their practice: a
preliminary study in the United Kingdom./Avis des
physiotherapeutes sur laspect psychologique de leur
profession: etude preliminaire au Royaume-Uni. Br J
Sports Med. 2002;36(1):6164. PubMed doi:10.1136/
bjsm.36.1.61
12. Heaney C. Physiotherapists perceptions of sport psychology intervention in professional soccer. Int J Sport Exerc
Psychol. 2006;4(1):6780.
13. Hussey L. A Study of the Psychological Views and
Strategies Used by Irish Chartered Physiotherapists
in Rehabilitating Injured Athletes [BSc dissertation].
University of Limerick; 2011. http://ulir.ul.ie/bitstream/
handle/10344/1518/2011_Hussey_L.pdf?sequence=5.
Accessed December 15, 2013.
14. Hamson-Utley JJ, Martin S, Walters J. Athletic trainers
and physical therapists perceptions of the effectiveness
of psychological skills within sport injury rehabilitation
programs. J Athl Train. 2008;43(3):258264. PubMed
doi:10.4085/1062-6050-43.3.258
15. Xinyi Z, Smith D, Adegbola O. Cross-cultural comparison
of six mental qualities among Singaporean, North American, Chinese and Nigerian professional athletes. Int J Sport
Exerc Psychol. 2004;2(2):103118. doi:10.1080/16121
97X.2004.9671735
16. Cox RH, Liu Z. Psychological skills: A cross-cultural
investigation. Int J Sport Psychol. 1993;24:326340.
17. Green LB. The use of imagery in the rehabilitation of
injured athletes. The Sport Psychol. 1992;6:416428.
18. Clement D, Arvinen-Barrow M. Sport medicine team
influences in psychological rehabilitation: a multidisciplinary approach. In: Arvinen-Barrow M, Walker N, eds.
The Psychology of Sport Injury and Rehabilitation. New
York, NY: Routledge; 2013:156170.
19. Voight M, Callaghan J. The use of sport psychology services at NCAA Division I universities from 19981999.
The Sport Psychol. 2001;15(1):91102.

JSR Vol. 24, No. 2, 2015

196Arvinen-Barrow et al

20. Roh JL, Perna FM. Psychology/counseling: a universal competency in athletic training. J Athl Train.
2000;35(4):458465. PubMed
21. Arvinen-Barrow M, Clement D, Hamson-Utley JJ, et al.
Athletes expectations about sport injury rehabilitation: a
cross-cultural study. Poster presented at The Association
for Applied Sport Psychology Annual Conference; 2013;
Las Vegas, NV.
22. Clement D, Hamson-Utley JJ, Arvinen-Barrow M, Kamphoff C, Zakrajsek RA, Martin SB. College athletes
expectations about injury rehabilitation with an athletic
trainer. Intl J Athl Ther Train. 2012;17(4):1827.
23. Brislin R. Back-translation for cross-cultural research.
J Cross Cult Psychol. 1970;1:185216. doi:10.1177/
135910457000100301
24. Arslan-zkan I, Okumus H, Aytekin Lash A, Ziya Firat
M. Cultural validation of the Turkish version of the
Infertility Self-Efficacy Scale-Short Form (TISE-SF). J
Transcult Nurs. 2013;25(3):232240. PubMed
25. Feltz DL, Landers DM. The effects of mental practice on
motor skill learning and performance: a meta-analysis. J
Sport Psychol. 1983;5(1):2557.
26. Beneka A, Malliou P, Bebetsos E, Gioftsidou A, Pafis
G, Godolias G. Appropriate counselling techniques for
specific components of the rehabilitation plan: a review
of the literature. Phys Train. 2007; Available http://ejmas.
com/pt/ptframe.htm.
27. Williams JM, Scherzer CB. Injury risk and rehabilitation:
Psychological considerations. In: Williams JM, ed. Applied
Sport Psychology: Personal Growth to Peak Performance.
New York, NY: McGraw Hill; 2010:512541.
28. Arvinen-Barrow M, Walker N, eds. Psychology of Sport
Injury and Rehabilitation. London, UK: Routledge; 2013.
29. Association for Applied Sport Psychology. About applied
sport & exercise psychology: common psychological skills
in the field of applied sport and exercise psychology. http://
www.appliedsportpsych.org/about/about-applied-sportand-exercise-psychology/. Accessed 2013.
30. Weinberg RS, Gould D. Foundations of Sport and Exercise
Psychology. 5th ed. Champaign, IL: Human Kinetics; 2011.
31. Estepp MK. NCAA Division I Athletic Trainers Perceptions and Use of Psychological Skills During Injury
Rehabilitation. Knoxville, TN: University of Tennessee;
2013.
32. Evans L, Hardy L. Injury rehabilitation: a qualitative
follow-up study. Res Q Exerc Sport. 2002;73:320329.
PubMed doi:10.1080/02701367.2002.10609026
33. Association for Applied Sport Psychology. Find a
consultant. http://www.appliedsportpsych.org/certifiedconsultants/find-a-consultant/. Accessed May 5, 2014.
34. American Psychological Association. Exercise and sport
psychology. http://www.apa.org/about/division/div47.
aspx. Accessed May 5, 2014.
35. British Psychological Society. Division of Sport and
Exercise Psychology. http://www.bps.org.uk/networksand-communities/member-networks/division-sport-andexercise-psychology. Accessed May 5, 2014.
36. Health and Care Professions Council. Practitioner
psychologist. http://www.hpc-uk.org/aboutregistration/

professions/index.asp?id=14#profDetails. Accessed May

5, 2014.
37. The British Association of Sport and Exercise Sciences.
Sport and exercise psychology: information on becoming
a practising sport and exercise psychologist. http://www.
bases.org.uk/Sports-Psychologist/2072. Accessed May 5,
2014.
38. Finnish Sport Psychology Association. Suomen urheilupsykologinen yhdistys [in Finnish]. http://supy.sporttisaitti.com/. Accessed May 5, 2014.
39. The Finnish Psychological Association. Urheilupsykologian alan sertifikaatit. http://www.psyli.fi/tietoa_psykologeista/urheilupsykologian_sertifikaatit. Accessed May 5,
2014.
40. Lavallee D, Jennnings D, Anderson AG, Martin SB. Irish
athletes attitudes toward seeking sport psychology consultation. Irish J Psychol. 2005;26(3-4):115121. doi:10.
1080/03033910.2005.10446214
41. Martin SB, Kellmann M, Lavallee D, Page S. Development and psychometric evaluation of the Sport Psychology
AttitudesRevised Form: a multiple group investigation.
The Sport Psychol. 2002;16(3):272290.
42. Martin SB. High school and college athletes attitudes
toward sport psychology consulting. J Appl Sport Psychol.
2005;17:127139. doi:10.1080/10413200590932434
43. Martin SB, Akers A, Jackson AW, et al. Male and female
athletes and nonathletes expectations about sport psychology consulting. J Appl Sport Psychol. 2001;13(1):1839.
doi:10.1080/10413200109339002
44. Martin SB, Lavallee D, Kellmann M, Page SJ. Attitudes
toward sport psychology consulting of adult athletes from
the United States, United Kingdom, and Germany. Int J
Sport Exerc Psychol. 2004;2:146160. doi:10.1080/1612
197X.2004.9671738
45. Hayden EW, Kornspan AS, Bruback ZT, Parent MC,
Rodgers M. The existence of sport psychology services among NCAA Division I FBS university athletic
departments and counseling centers. The Sport Psychol.
2013;27(3):296304.
46. National Athletic Trainers Association. National Athletic
Trainers Association recommendations and guidelines for
appropriate medical coverage of intercollegiate athletics.
http://www.nata.org/sites/default/files/AMCIARecsandGuides.pdf. Accessed August 19, 2014.
47. National Athletic Trainers Association. Athletic Training
Educational Competencies. 5th ed. Dallas, TX: National
Athletic Trainers Association; 2011.
48. Board of Certification, Inc. Role delineation study/practice
analysis. http://www.bocatc.org/resources/role-delineation-study-practice-analysis. Accessed May, 5, 2014.
49. Heaney C, Green AJK, Rostron CL, Walker N. A qualitative and quantitative investigation of the psychology
content of UK physiotherapy education programs. J Phys
Ther Ed. 2012;26(3):2456.
50. Ievleva L, Orlick T. Mental links to enhanced healing: an
exploratory study. The Sport Psychol. 1991;5(1):2540.
51. Larson GA, Starkey C, Zaichkowsky LD. Psychological
aspects of athletic injuries as perceived by athletic trainers.
The Sport Psychol. 1996;10(1):3747.

JSR Vol. 24, No. 2, 2015

Mental Skills in Sport Injury Rehabilitation 197

52. Arvinen-Barrow M, Penny G, Hemmings B, Corr S. UK

chartered physiotherapists personal experiences in using
psychological interventions with injured athletes: an interpretative phenomenological analysis. Psychol Sport Exerc.
2010;11(1):5866. doi:10.1016/j.psychsport.2009.05.004
53. Jevon SM, Johnston LH. The perceived knowledge
and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation. Phys Ther Sport. 2003;4(2):7481. doi:10.1016/
S1466-853X(03)00034-8
54. Heaney C. Recommendations for successfully integrating
sport psychology into athletic training. Athl Ther Today.
2006;11(2):6062.
55. Ahern DK, Lohr BA. Psychosocial factors in sports injury
rehabilitation. Clin Sports Med. 1997;16(4):755768.
PubMed doi:10.1016/S0278-5919(05)70052-1
56. Granquist MD, Hamson-Utley JJ. Psychosocial antecedents to injury. In: Granquist MD, Hamson-Utley JJ,
Kenow L, Ostrowski JA, eds. Psychosocial Strategies for

Athletic Trainers: An Applied and Integrated Approach.

Philadelphia, PA: FA Davis; 2014.
57. Kamphoff C, Thomae J, Hamson-Utley JJ. Integrating
the psychological and physiological aspects of sport
injury rehabilitation: rehabilitation profiling and phases
of rehabilitation. In: Arvinen-Barrow M, Walker N, eds.
Psychology of Sport Injury and Rehabilitation. New York,
NY: Routledge; 2013:134155.
58. Zizzi SJ, Blom LC, Watson JC, II, Downey VP, Geer J.
Establishing a hierarchy of psychological skills: coaches,
athletic trainers, and psychologists uses and perceptions
of psychological skills training. Athl Insight. 2009;11(2).
http://www.athleticinsight.com/Vol11Iss2/Feature.htm.
59. Shapiro JL. An Individualized Multimodal Mental Skills
Intervention for College Athletes Undergoing Injury Rehabilitation. Morgantown, WV: West Virginia University;
2009.
60. Taylor J, Taylor S. Psychological Approaches to Sports
Injury Rehabilitation. Gaithersburg, MD: Aspen; 1997.

JSR Vol. 24, No. 2, 2015

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