From a gymnast hiding ankle pain so she can compete to a basketball player who withdraws from friends after a season-ending injury, it can be argued that every sport injury affects or is affected in some way by psychological factors. Given the widespread importance of psychological issues in sport injury, it is important for those working with athletes—injured or not—to be aware of the latest developments on the subject.
Written by a sport psychology consultant and an athletic trainer, Psychology of Sport Injury provides a thorough explanation of the elements and effects of sport injuries along with up-to-date research and insights for practical application. The authors offer a contemporary approach to preventing, treating, rehabilitating, and communicating professionally about sport injuries that takes into account physical, psychological, and social factors.
Psychology of Sport Injury presents sport injury within a broader context of public health and offers insights into the many areas in which psychology may affect athletes, such as risk culture, the many facets of pain, athlete adherence to rehab regimens, the relationship between psychological factors and clinical outcomes, collaboration, and referrals for additional support. The book explores the relevant biological, psychological, and social factors that affect given circumstances. The text consists of four parts: Understanding and Preventing Sport Injuries, Consequences of Sport Injury, Rehabilitation of Sport Injury, and Communication in Sport Injury Management.
Psychology of Sport Injury includes evidence-based examples and demonstrates real-world applications that sport health care professionals often face with athletes. Additional pedagogical features include the following:
• Focus on Research boxes provide the what and why of the latest research to complement the applied approach of the text.
• Focus on Application boxes highlight practical examples to illustrate the material and maintain student engagement.
• Psychosocial content aligned with the latest educational competencies of the National Athletic Trainers’ Association (NATA) helps students prepare for athletic training examinations and supports professional development for practitioners.
• A prevention-to-rehabilitation approach gives a framework for understanding sport injury, including precursors to injury, pain as a complex phenomenon, adherence to rehabilitation, and communication and management of injuries with other health care professionals as well as the athlete.
• A set of chapter quizzes and a presentation package aid instructors in testing student comprehension and preparing lectures.
Psychology of Sport Injury is an educational tool, reference text, and springboard to new ideas for research and practice in any line of work exposed to sport injury. Observing and committing to athletes, especially during times of physical trauma and emotional distress (which are often not separate times), are critical skills for athletic trainers, physical therapists, sport psychologists, coaches, and others who work with athletes on a regular basis.
Part I. Understanding and Preventing Sport Injuries
Chapter 1. Biopsychosocial Foundations of Sport Injury
A Biopsychosocial Perspective on Sport Injury
Biological Foundations of Sport Injury
Psychological Foundations of Sport Injury
Social Foundations of Sport Injury
Biopsychosocial Analysis
Summary
Chapter 2. Antecedents of Sport Injury
Models of Sport Injury Occurrence
Psychosocial Predictors of Sport Injury
Mechanisms of Psychosocial Influence on Sport Injury Occurrence
Biopsychosocial Analysis
Summary
Chapter 3. Sport Injury Prevention
Types of Prevention
Models of Sport Injury Prevention
Sport Injury Prevention Content Categories
Biopsychosocial Analysis
Summary
Part II. Consequences of Sport Injury
Chapter 4. Psychological Responses to Sport Injury
Models of Psychological Response to Sport Injury
Psychological Consequences of Sport Injury
Biopsychosocial Analysis
Summary
Chapter 5. Pain, Sport, and Injury
Definitions of Pain
Types of Pain
Dimensions of Pain
Measurement of Pain
Models and Theories of Pain
Factors Associated with Pain in Sport
Interpreting and Acting on Sport-Related Pain
Biopsychosocial Analysis
Summary
Part III. Rehabilitation of Sport Injury
Chapter 6. Adherence to Sport Injury Prevention and Rehabilitation Programs
Adherence to Sport Injury Prevention Programs
Adherence to Sport Injury Prevention Programs
Consequences of Adherence to Sport Injury Prevention and Rehabilitation Programs
Biopsychosocial Analysis
Summary
Chapter 7. Psychological Factors in Sport Injury Rehabilitation
Sport Injury Rehabilitation Outcomes
Charting a Course from Psychological Factors to Sport Injury Rehabilitation Outcomes
Psychological Readiness to Return to Sport
Biopsychosocial Analysis
Summary
Chapter 8. Psychological Interventions in Sports Health Care
Psychological Interventions in Sports Health Care
Biopsychosocial Analysis
Summary
Part IV. Communication in Sport Injury Management
Chapter 9. Communicating with Patients
Context of Patient-Practitioner Communication in Sports Health Care
Models of the Patient-Practitioner Relationship in Sports Health Care
Congruence of Patient-Practitioner Perceptions in Sports Health Care
Factors Affecting Patient-Practitioner Communication in Sports Health Care
Biopsychosocial Analysis
Summary
Chapter 10. Referring Athletes for Psychological Services
Definition of and Rationale for Referral of Athletes for Psychological Services
Socioclinical Context of Referral of Athletes for Psychological Services
Reasons for Referral
Referral Process
Biopsychosocial Analysis
Summary
Britton W. Brewer, PhD, is a professor of psychology at Springfield College, where he has taught graduate and undergraduate classes and conducted research on psychological aspects of sport injury since 1991. He is a fellow of the American Psychological Association and the Association of Applied Sport Psychology and a certified consultant with the Association of Applied Sport Psychology. He has edited four books on sport psychology, authored or coauthored more than 100 articles in refereed journals (approximately 40 percent of which are on topics related to the psychology of sport injury), and authored or coauthored 28 book chapters (more than half of which are on topics related to the psychology of sport injury). He has been awarded more than $1,000,000 in grant funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases for his research on psychological aspects of anterior cruciate ligament (ACL) surgery and has received research awards from Divisions 22 (Rehabilitation Psychology) and 47 (Exercise and Sport Psychology) of the American Psychological Association.
Charles J. Redmond, MS, MEd, ATC, LAT, PT, is professor emeritus of exercise science and sport studies and retired dean of the School of Health, Physical Education and Recreation at Springfield College, where he has been a member of the faculty since 1969. He has extensive clinical, teaching, and administrative experience in athletic training and has served in multiple leadership positions in the National Athletic Trainers’ Association. He received the Most Distinguished Athletic Trainer Award from the NATA in 1994 and was inducted into the NATA Hall of Fame in 2004. He has also been inducted into the Athletic Trainers of Massachusetts Hall of Fame and the Springfield College Athletic Hall of Fame. He served on the editorial advisory board of Athletic Therapy Today from 1995 to 2005, during which he was theme editor for issues such as eating and exercise disorders, psychosocial factors and athletic therapy, and advances in the management of patellofemoral pain. He has given presentations and conducted workshops on a variety of topics in sport health care, including the psychology of sport injury.
“This text clearly fills a need. As injury management has become more evidence-based from a physical standpoint, more information to address the psychological aspects of injury are needed to complement this approach.”
—Kent Scriber, EdD, ATC, PT, FNATA-- Ithaca College
Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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Work to establish effective injury prevention measures
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner.
Models of Sport Injury Prevention
Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.
Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.
The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.
In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes', coaches', and administrators' knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter's Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).
Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.
The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.
The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).
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Help athletes stick to an injury prevention program
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions.
Adherence to Sport Injury Prevention Programs
As discussed in chapter 3, recent years have brought a surge in attempts to prevent the occurrence of sport injuries. This surge has been accompanied by growing recognition of the vital importance of adherence both in preventing sport injuries and in documenting the effectiveness of preventive interventions (C.F. Finch & Donaldson, 2010; Van Tiggelen, Wickes, Stevens, Roosen, & Witvrouw, 2008). C.F. Finch (2006) asserted that in order to "prevent injuries, sports injury prevention measures need to be acceptable, adopted, and complied with by the athletes and sports bodies they are targeted at" (p. 5). Unfortunately, the extent of adoption and adherence by targeted groups and individuals has not routinely been considered in research studies (C.F. Finch, 2011). When adherence rates have been assessed, they have been found to vary considerably - ranging from not at all (Duymus & Gungor, 2009) to 100 percent (Heidt, Sweeterman, Carlonas, Traub, & Tekulve, 2000) - depending on the population under consideration and on how adherence was measured.
Although preventive efforts can involve administrators, legislators, and sport health care professionals, this part of the chapter focuses on adoption of preventive behaviors by athletes. Preventive behaviors that athletes may be encouraged to adopt include completing physical exercises (e.g., warm-up, stretching, strengthening, agility, jumping, balance), hydrating, wearing protective equipment, and doing stress management activities (e.g., Emery & Meeuwisse, 2010; Gissane, White, Kerr, & Jennings, 2001; Perna et al., 2003). The following sections address adherence to sport injury prevention programs in terms of measurement, theories, predictors, and enhancement of adherence.
Measurement
It is not possible to evaluate the effectiveness of sport injury prevention programs without knowing how well athletes adhere to the behavioral aspects of those programs. For example, if a program is found to be ineffective but the athletes did not adhere to it, then one cannot determine whether the program simply does not work or whether it would work if athletes adhered to it. Knowledge of adherence can be obtained only by operationally defining and measuring the construct. Consequently, both practitioners and researchers have a stake in measuring adherence.
Sport injury prevention activities can be implemented in both team and individual settings. The most common method of measuring adherence to sport injury prevention programs in team settings has been for coaches to keep a record of training sessions in which the prevention program was implemented and, in some cases, which athletes attended each session. These data can be used to calculate adherence indexes, such as the percentage of team training sessions in which the prevention program was implemented, the percentage of players on the team who completed a requisite number of training sessions that included the program, and a composite that accounts for both team and individual completion of prevention program sessions (e.g., Junge et al., 2011; Keats, Emery, & Finch, 2012; Soligard et al., 2008; Soligard, Nilstad, et al,. 2010; Sugimoto et al., 2012; van Beijsterveldt, Krist, van de Port, & Backx, 2011a, 2011c). Adherence to preventive activities completed on an individual basis - away from the team environment - has been assessed with self-report questionnaires (Chan & Hagger, 2012a; Emery, Rose, McAllister, & Meeuwisse, 2007).
Adherence reports from both coaches and athletes are subject to the usual potential limitations of self-report assessment - for example, forgetting, inaccuracy, andsocially desirable responses. However, in at least one investigation of the effectiveness of an injury-prevention training program, coach reports were verified and validated through monitoring by independent observers (van Beijsterveldt, Krist, van de Port, & Backx, 2011a). Independent observers have also been used to monitor and record athletes' use of protective equipment, such as headgear and mouth guards (Braham & Finch, 2004). On the whole, measurement of adherence to sport injury prevention programs is still in the early stages. More sophisticated measures are needed in order to capture aspects of adherence that are not typically examined (e.g., intensity of effort and use of proper technique during neuromuscular training) and to assess adherence more objectively (Chan & Hagger, 2012a).
Theoretical Perspectives
Theory helps us understand the processes by which athletes adopt preventive behaviors; it also guides the implementation of preventive interventions.
Until recently, the examination of adherence to sport injury prevention programs had been a largely atheoretical enterprise. Adherence had been assessed in epidemiological studies examining the prevalence of various preventive behaviors and in trials evaluating the effectiveness of prevention programs, but few researchers had made theory-guided attempts to understand why athletes adhere or do not adhere to the preventive activities. Indeed, a review (McGlashan & Finch, 2010) of 100 studies identified as investigating safety behaviors in association with sport injury prevention - the vast majority of which addressed the wearing of protective equipment - found that only 11 studies deployed theories or models from the behavioral and social sciences.
The onlytheoretical perspective used in more than two studies involved the theory of reasoned action (TRA; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), including its extension, the theory of planned behavior (TPB; Ajzen, 1991). When the TRA is adapted to behavior designed to prevent sport injury, it holds that the likelihood of engaging in preventive behavior is influenced directly by the intention to engage in such behavior. Intention, in turn, is affected by an athlete's attitudes toward the preventive behavior, as well as the opinions held by others in the athlete's social environment (i.e., subjective norms). In TPB, Ajzen (1991) added a third contributor to the athlete's intention to complete the preventive behavior - namely, the athlete's beliefs about personal control over the behavior. Therefore, from the perspective of TPB, adherence to sport injury prevention programs would be highest when
- athletes and their associates value the preventive behavior and its potential beneficial outcomes;
- athletes perceive themselves as having control over the preventive behavior; and
- as a direct consequence of the preceding two items, athletes intend to engage in the preventive behavior.
Noting the widespread support for TPB in the physical activity domain, Keats et al. (2012) advocated integrating it with self-determination theory (SDT; R.M. Ryan & Deci, 2000), a perspective thought to aid understanding of why athletes develop certain attitudes, beliefs, and intentions about behaviors designed to prevent sport injury. Specifically, athletes would be expected to value, perceive the support of others for, perceive control over, and intend to engage in preventive behavior when they experience satisfaction of basic psychological needs for autonomy, competence, and relatedness. Athletes experience autonomy when their decisions to complete preventive behavior are self-determined - that is, motivated by intrinsic factors (within the self) as opposed to extrinsic factors (outside the self). In addition, to the extent that the athletes perceive preventive behavior as being linked to sport success and favorable interpersonal relationships with important others (e.g., coaches, teammates), their needs for competence and relatedness are satisfied and TPB components conducive to adherence are elicited (Chan & Hagger, 2012b; Keats et al., 2012).
Figure 6.1 presents a graphic depiction of the model integrating TPB and SDT. Preliminary support has been found for SDT tenets in predicting athletes' motivation to engage in behaviors that reduce their risk of sport injury (Chan & Hagger, 2012a). With this in mind, an integrated approach such as that proposed by Keats et al. (2012) shows considerable promise as a means of understanding adherence to sport injury prevention programs and guiding the implementation of such programs.
Model depicting integration of self-determination theory and the theory of planned behavior.
Sports Medicine, "Theoretical integration and the psychology of sport injury prevention, 42: 725-732, 2012, D.K. Chan and M.S. Hagger, Adis ©2012 Springer International Publishing AG. With permission of Springer.
Predictors
The general lack of theory-based research on factors associated with adherence to sport injury prevention programs has resulted in a hodgepodge of predictors of preventive behavior that lacks organizing themes. For the sake of discussion, the predictors can be divided into intrinsic factors and extrinsic factors, depending on whether they reside inside or outside of the individual. Intrinsic factors include injury history, personal characteristics, and cognitive variables. Athletes with a previous injury in a part of the body that can beprotected by a particular kind of equipment (e.g., lower extremity, eyes, mouth) have been found more likely than those without such an injury to wear protective gear during sport participation (Cornwell, Messer, & Speed, 2003; Eime, Finch, Sherman, & Garnham, 2002; Yang et al., 2005). With respect to personal characteristics, some evidence suggests that athletes who are older (Cornwell et al., 2003; Eime et al., 2002; Yang et al., 2005) or more experienced (Eime et al., 2002) use protective equipment to a greater extent than do their younger, less experienced counterparts - and that female athletes are more likely than male athletes to wear protective gear (Yang et al., 2005). For neuromuscular training, however, experience was inversely related to adherence for both coaches and athletes (McKay, Steffen, Romiti, Finch, & Emery, 2014).
The cognitive factors found to predict adherence to sport injury prevention programs include the intention to adhere, self-efficacy expectations, knowledge of injury risk, and a host of theoretically derived attitudes and beliefs. Athletes have been found to be more likely to wear protective gear when they are confident in their ability to wear the gear, intend to wear it (De Nooijer, De Wit, & Steenhuis, 2004), possess knowledge of injury risk (Eime et al., 2002), perceive fewer barriers to wearing gear, perceive themselves as susceptible to injury without gear, perceive injuries incurred without gear to be severe, and perceive more benefits to wearing gear (R.M. Williams-Avery & MacKinnon, 1996).
In the most extensive examination of adherence to sport injury prevention activities - which involved a sample of elite athletes in a variety of sports - Chan and Hagger (2012b) documented positive associations between a wide array of cognitive factors and a composite of behaviors considered to be protective against sport injury (e.g., warming-up, stretching, resting adequately, icing, taking supplements). Consistent with self-determination theory (R.M. Ryan & Deci, 2000), the study also found that greater self-reported adoption of protective behaviors was related to high levels of general factors such as satisfaction of basic psychological needs, self-determination for sport, and self-determination for injury prevention. Adherence was also positively correlated with several highly specific attitudes and beliefs. Some of the correlations were consistent with what would be expected, such as those involving beliefs about commitment to safety, worry about sport injury, and prioritization of injury prevention activities. Other correlations were the opposite of what would be anticipated, such as those involving attitude toward safety violations (i.e., viewing safety violations as sometimes necessary in pursuit of sport performance) and fatalism about injury prevention (i.e., viewing sport injury as unavoidable). Additional research is needed to clarify the nature of the relations between these specific attitudes and adherence to sport injury prevention activities.
Extrinsic factors associated with adherence to sport injury prevention programs include social influences and program and implementation features. In terms of social influences, athletes have demonstrated greater adherence to preventive behaviors when a large proportion of their teammates or friends are adhering (De Nooijer et al., 2004; Yang et al., 2005), when they perceive a high degree of support for autonomy (Chan & Hagger, 2012a), and when they report experiencing pressure from their parents to adhere (De Nooijer et al., 2004). Program and implementation features involve characteristics of prevention programs and the ways and contexts in which they are implemented with athletes. For example, athletes attending small high schools with low player-to-coach ratios have been found to wear protective equipment to a greater extent than do athletes at larger schools with higher ratios (Yang et al., 2005). Similarly, Australian squash players were more likely to wear protective eyewear when posters and stickers reminded them to do so and when the eyewear was readily available (Eime, Finch, Wolfe, Owen, & McCarty, 2005).
In the case of neuromuscular training programs designed to prevent musculoskeletal injuries, adherence is associated with the following program and implementation features: The program focuses on performance enhancement rather than injury prevention (Alentorn-Geli et al., 2009; Hewett, Ford, & Myer, 2006); it is not perceived by coaches as being too time consuming (Soligard, Nilstad, et al., 2010); and it is implemented by coaches (Hewett et al., 2006), especially those who have previously used prevention practices and perceive the athletes as highly motivated (Soligard, Nilstad,et al., 2010). Thus, athletes' level of adherence to preventive interventions is likely influenced not only by factors within the athletes themselves but also by other people and by characteristics of the interventions and their implementation.
Barriers to adoption of preventive measures, though not technically predictive of adherence to sport injury prevention programs, are directly relevant to adherence. To put it simply, when athletes perceive barriers to adherence, they may be less likely to adhere. In studies of the use of protective equipment (e.g., eyewear, headgear, mouth guards) during sport participation, athletes have identified a number of reasons for not wearing protective gear. Examples include cost (Chatterjee & Hilton, 2007; Pettersen, 2002), difficulty breathing (P.J. Chapman, 1985), difficulty communicating (C.F. Finch, McIntosh, & McCrory, 2001), dislike (Braham et al., 2004), restricted vision (Eime et al., 2002), transportationdifficulties (Chatterjee & Hilton, 2007; Pettersen, 2002), and discomfort (Braham, Finch, McIntosh, & McCrory, 2004; C.F. Finch et al., 2001; Pettersen, 2002; Schuller, Dankle, Martin, & Strauss, 1989; Upson, 1982).
Enhancement
Although adherence is becoming increasingly recognized as vital to the success of sport injury prevention programs, only limited attempts have been made to improve the potency of preventive interventions by enhancing adherence. One important step toward boosting adherence is that of incorporating behavioral theory into the design and implementation of sport injury prevention programs (McGlashan & Finch, 2010). Consistent with the recommendations of C.F. Finch (2006), more rigorous, systematic, experimental, theory-based exploration of factors associated with adherence can inform the development and evaluation of meta-interventions (i.e., interventions for interventions) - that is, procedures intended to facilitate adoption of and adherence to preventive interventions. For example, we can systematically manipulate key components of the model integrating TPB and SDT (described earlier in this chapter) and various predictors of adherence (identified in the preceding section) to determine features of prevention programs that optimize adherence to - and, ultimately, the preventive impact of - the interventions.
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Communicate effectively with patients to enhance recovery
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties.
Enhancing Patient - Practitioner Communication
As the preceding sections indicate, important outcomes are associated with the quality of patient - practitioner communication, which serves key informational and socioemotional functions in sport health care. However, significant discrepancies have been documented between the perceptions reported by patients and those reported by practitioners; therefore, we have much to gain by enhancing communication between the two parties. This goal has been pursued by means of two main approaches - interventions with practitioners and interventions with patients.
Interventions With Practitioners
Having recognized the advantages of physicians being attuned to the needs of their patients, medical schools have developed training programs to help doctors communicate more effectively with patients. These programs typically target common interpersonal courtesies (e.g., greeting patients by name, explaining procedures, saying goodbye), discussion of sensitive or difficult health topics, delivery of bad news, patient education, and how to help patients ask questions and remember key information. To help doctors develop such communication skills, training programs use video feedback and role-play exercises (Straub, 2012; S.E. Taylor, 2012). Similar coursework has been implemented with physical therapists and found effective in improving their communication skills (Ladyshewsky & Gotjamanos, 1997; Levin & Riley, 1984).
Although communication skills are recognized as vital to the practice of sport health care (Ray, Terrell, & Hough, 1999), relevant training for sport health care professionals has not reached the level of that found in medical schools on a consistent basis. With an eye toward addressing this gap, Gordon, Potter, and Ford (1998) proposed an extensive psychoeducational curriculum for sport health care professionals that prominently featured both lecture and applied experiences devoted to building communication skills in the context of sport health care. However, this curriculum has remained in prototype form and has not been implemented on a widespread basis. Even so, many sport health care professionals do receive some training in relevant communication skills through coursework in counseling. Basic counseling skills overlap heavily with the communication skills used in sport health care and therefore can help sport health care professionals build effective working alliances with patients.
In the context of sport health care, working alliances are relationships in which professionals and athletes collaborate to help athletes manage their injuries. A working alliance is designed to create an environment of trust and unified purpose, thus forging an emotional bond between the sport health care professional and the athlete and ensuring that the two parties are in agreement with respect to the goals and methods of treatment (Petitpas & Cornelius, 2004). Based on the influential work of Carl Rogers (1957), Petitpas and Cornelius suggested that an effective working alliance with an athlete depends on the practitioner's ability to communicate genuineness, acceptance, and empathy. Practitioners exhibit genuineness when they are true to themselves, aware of and open to appropriately sharing their feelings, and able to display nonverbal communication that is consistent with their verbal communication. Practitioners convey acceptance when they demonstrate unconditional positive regard for athletes and show respect for them regardless of what they do, think, or feel. Finally, practitioners display empathy when they show understanding of athletes' feelings and experiences from the athletes' perspectives. By communicating genuineness, acceptance, and empathy to athletes with injuries, sport health care professionals can facilitate the creation of an atmosphere of trust, caring, and understanding in which a working alliance can grow and thrive (Petitpas & Cornelius, 2004).
So, how exactly do sport health care professionals go about communicating genuineness, acceptance, and empathy? Learning and implementing basic counseling skills may help practitioners not only accomplish this goal but also help them put into practice their knowledge about patient - practitioner communication (e.g., informational and socioemotional functions, verbal and nonverbal modes). Basic counseling skills can be organized and described according to multiple models (e.g., Culley & Bond, 2007; Egan, 2014; Ivey, Ivey, & Zalaquett, 2013; Kottler, 2003; M.E. Young, 2012). These frameworks vary with respect to terminology and skill categorization but feature substantially similar behaviors. Specifically, in the context of sport health care, basic counseling skills can be divided into three groups based on their main function: attending to athletes and their concerns, exploring athletes' current concerns, and influencing athletes' thoughts or behaviors pertaining to their current concerns. These three types of skill are neither discrete nor mutually exclusive; rather, the boundaries between the categories are permeable - for example, there is no clear line at which exploring ends and influencing begins - and some skills (e.g., listening) overlap more than one category. Still, for the purpose of understanding, it is useful to examine each type individually.
Attending Skills
Also known as "invitational skills" (M.E. Young, 2012), attending skills involve verbal and nonverbal behaviors that convey the practitioner's interest in "tuning in" (Egan, 2014) or listening to what athletes with injury have to say. As the term implies, attending involves paying attention to athletes, which can be communicated nonverbally by maintaining direct eye contact (as appropriate, without staring), displaying receptive body language (e.g., encouraging gestures and facial expressions, relaxed posture, slight forward lean facing athletes at a socially appropriate conversational distance), and using appropriately varied vocal tones (Culley & Bond, 2007; Ivey et al., 2013; Kottler, 2003; M.E. Young). Verbal indicators, on the other hand, include inviting athletes to speak and staying on the topics that they bring up (Ivey et al.; M.E. Young). When practitioners give their attention to athletes and show their willingness to listen, they communicate genuineness and acceptance right from the start (Waumsley & Katz, 2013).
Exploring Skills
Through the process of exploration, sport health care professionals and athletes alike can learn more about the athletes' current concerns. Exploring typically begins when the practitioner asks questions. As discussed earlier in this chapter, the various types of question - closed, open, and focused - can generate different sorts of response from athletes. After the use of questioning gets the conversation started, the professional can help continue it by restating a few key words or phrases uttered by the athlete (e.g., "skiing career went kaput," "trained too hard") or by using brief statements that nudge athletes gently without intruding on their ideas (e.g., "tell me more," "uh huh," "and . . ."). Such encouragement not only stimulates conversation but also serves as an important form of active listening to the athlete's responses. Whereas passive listening involves merely hearing what another person says, active listening involves making a conscious effort to understand what the person is saying and communicating that effort back to the person, along with any understanding gained (Culley & Bond, 2007; Kottler, 2003).
Other forms of active listening include paraphrasing, reflecting feeling, and summarizing (Culley & Bond, 2007; Egan, 2014; Ivey et al., 2013; Kottler, 2003; M.E. Young, 2012). Paraphrasing involves repeating back to athletes key portions of their statements in an abbreviated form that uses at least some of their own words (e.g., "so the ‘swelling has gone down' but your knee is ‘even wobblier than it was before'"). Reflecting feeling involves identifying the athletes' emotions based on their verbal or nonverbal communication (e.g., "sounds like you're feeling pretty angry about how your surgery has turned out so far"). Whereas paraphrasing deals with thought content, reflecting feeling addresses emotional content; essentially, it involves paraphrasing athletes' expression of emotion. When sport health care professionals engage in summarizing, they offer athletes a pithy, organized account of the thoughts, feelings, behaviors, and meanings the athletes have conveyed in the interview.
The active listening skills of encouraging, paraphrasing, reflecting feeling, and summarizing serve multiple purposes in the process of exploration. Using these skills can be instrumental in helping sport health care professionals convey empathy to athletes and further demonstrate that the professionals are attending to the athletes (i.e., are interested in and willing to hear what they have to say). Practitioners can also use athletes' responses to these techniques to confirm or correct their understanding of what the athletes have been telling them.
Influencing Skills
For most sport health care professionals, the acquisition of attending skills and exploring skills provides a sufficient foundation for enhancing their ability to communicate with athletes. These skills enable practitioners to listen to patients, gain understanding of what they are experiencing, build rapport, express empathy, and solidify a working alliance. Although these skills are clearly nondirective, they are generally highly effective for collecting information and connecting with patients. Nevertheless, proficiency in the use of influencing skills can also be advantageous in the practice of sport health care. As implied by the term, influencing skills involve a more directive approach in which practitioners try to foster alternative ways for patients to think, feel, and act regarding their interactions in the world. There are three main clusters of influencing skills that vary in terms of whether they attempt to alter patients' cognitive processes, furnish patients with information, or prompt patients to act in some clearly defined way.
Two related influencing skills aimed at affecting patients' cognitive processes are reframing and focus analysis. Reframing, which is sometimes referred to as interpretation, involves encouraging athletes to think about a situation from a different, potentially more adaptive point of view (e.g., "So, you've told me a lot of ways that your injury has been problematic for you. What's on the other side of the ledger? What positive things have you experienced as a result of your injury?"). In a similar vein, focus analysis asks athletes to consider multiple aspects of a problem or situation. As shown in table 9.2, athletes can be asked to consider their injury using a patient (athlete) focus; an "other" focus; a family focus; a problem or main-theme focus; a practitioner focus; a patient - practitioner ("we") focus; or a cultural, environmental, or context focus. The locus (or type) of focus varies as deemed appropriate to facilitate understanding of the problems or situations experienced by the athlete. Although this type of analysis typically emphasizes helping athletes understand themselves and their concerns from their own perspective, it is sometimes valuable to broaden the focus in order to gain a fuller, more complete understanding of the pertinent issues and - when the "we" focus is involved - a better sense of what is happening in the patient - practitioner relationship (Ivey et al., 2013).
Another group of influencing skills involves providing patients with information designed to affect their thoughts or behaviors. Examples include providing advice or other information, self-disclosure, feedback, logical consequences, instruction or psychoeducation, and confrontation. Giving advice, a technique that is best used sparingly, involves recommending a course of action for the patient to take or furnishing the patient with new information that might be useful. Self-disclosure involves sharing current or past personal experiences with the patient (e.g., "Yeah, I know what you mean. I had to do rehab after ankle surgery a while back. It was pretty frustrating to see a lack of progress from day to day, but I guess I wanted it and stuck with it anyway."). Although self-disclosure can help build trust between patients and practitioners, the practitioner should be cognizant of whose needs are being served by disclosing the personal information.
Another skill in this group - feedback - involves letting patients know how their behavior is perceived by the practitioner and other people (e.g., "From what I've seen of your interactions with our staff, I have the impression that you've been quite angry these past few weeks"). A related skill - the use of logical consequences - involves informing patients about likely outcomes of their behavior (e.g., "As you might suspect, skipping your rehabilitation exercises may come back to bite you down the road in terms of a restricted range of motion and increased risk for injury in the future."). In using instruction, or psychoeducation, practitioners explicitly teach patients skills that may enhance their psychological state. Although instruction of some type accounts for a large part of what many sport health care professionals do, the skills they teach are often physical or technical in nature (as discussed later in this chapter). Psychoeducational content, of course, is most likely to be taught by sport health care professionals whose work with athletes is geared primarily toward effecting changes in psychological factors (e.g., cognition, emotion, behavior) - for example, sport psychology consultants and mental health specialists.
A third cluster of influencing skills includes techniques that issue a call to action - rather than providing information - intended to affect the patient's cognitions, emotions, behavior, or a combination thereof. Skills in this category include the use of confrontation, directives, goal setting, problem solving, stress management, reinforcement, and therapeutic lifestyle changes. In confrontation, which is far less adversarial than the term implies, practitioners note and bring to the patient's attention discrepancies in how the patient is thinking, feeling, and behaving. For example, if an athlete has repeatedly missed supervised rehabilitation sessions, the practitioner might say, "Throughout your rehabilitation, you've talked about how important it is for you to return to your sport as quickly as you can. Your actions, however, don't seem to match your stated goal. You're missing a lot of your appointments and seem to be going through the motions when you're here. What do you think is going on?" The next technique - using directives - is similar to giving advice or information in that it involves asking (rather than recommending or suggesting) that the patient take a particular course of action (e.g., "Today, I would like for you to do three sets of 15 reps at each station"). Because directives have the potential to undermine the patient's autonomy, they (like the sharing of advice, information, and self-disclosure) should be used with discretion.
The next three skills - goal setting (discussed in detail in chapter 8), problem solving, and stress management - are pragmatic influencing skills with which practitioners can help patients achieve clearly defined ends. In goal setting, for example, practitioners help patients set and pursue goals and evaluate their attainment of those goals. Similarly, in problem solving, practitioners guide patients through the process of defining problems, developing plans to address those problems, selecting the best plans, implementing the chosen plans, and evaluating the effectiveness of the chosen course of action (i.e., whether the plan worked). In stress management, practitioners help patients identify stressors and devise, implement, and evaluate plans to manage them.
The final two skills are reinforcement and therapeutic lifestyle changes. Reinforcement is a widely applicable skill that involves providing support and encouragement for patient behaviors deemed desirable (e.g., completing rehabilitation exercises, asking questions about rehabilitation). The practitioner can also help patients implement therapeutic lifestyle changes (e.g., regarding diet, smoking, exercise) to enhance both their general health and their injury-related health (Egan, 2014; Ivey et al., 2013; Kottler, 2003).
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