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AN EVALUATION OF AN EDUCATIONAL INTERVENTION IN
PSYCHOLOGY OF INJURY FOR ATHLETIC TRAINING
STUDENTS

presented by

JENNIFER LYNN STILLER

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5/08 K'IPrOIIAccaPres/CIRC/DateDue indd

 

AN EVALUATION OF AN EDUCATIONAL INTERVENTION IN PSYCHOLOGY
OF INJURY FOR ATHLETIC TRAINING STUDENTS

By

Jennifer Lynn Stiller

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Kinesiology

2008

ABSTRACT

AN EVALUATION OF AN EDUCATIONAL INTERVENTION IN PSYCHOLOGY
OF INJURY FOR ATHLETIC TRAINING STUDENTS

By

Jennifer Lynn Stiller

This dissertation has two purposes: (a) to identify the psychosocial competencies
that are needed by certified athletic trainers; and (b) to evaluate whether these
competencies can be taught to athletic training students (ATS). It includes an
introduction (Chapter I), a review of literature. (Chapter 2). two background studies
(Chapter 3). the dissertation study (Chapter 4), and one comprehensive discussion
(Chapter 5). The purpose of the two background studies contained in Chapter 3 was to
identify the psychosocial competencies that are needed by certified athletic trainers
(ATCs). This was accomplished through individual interviews with currently or
previously injured college student-athletes and through focus group interviews with
recently certified athletic trainers. Results of these two background studies were
triangulated with information obtained from the review of literature (Chapter 2) to
produce content to be included in athletic training education programs. The purpose of
the main dissertation study (Chapter 4) was to evaluate the effectiveness of an
educational module in teaching these competencies to athletic training students. Chapter
4 also contains a discussion of the development of two psychometrically sound
questionnaires designed to measure the application and transfer of sport psychology
knowledge and applied sport psychology techniques. Chapter 5 is dedicated to a

discussion of the implications of the results of the studies contained within Chapter 3 and

Chapter 4. In the primary dissertation study (Chapter 4), 3l athletic training students
were assigned to an intervention versus a control condition and took part in six—week
Applied Sport Psychology for Athletic Trainers (ASP-AT) educational module designed
to increase proficiency in psychology of injury competencies. Assessments of
psychology of injury knowledge and usage occurred at multiple occasions, extending 14
weeks post-intervention. Results indicated that the ASP—AT educational module is
effective at increasing psychology of injury knowledge (increase of 31 points from
baseline) and skill usage (increase of 44 points from baseline) in undergraduate and
Masters degree candidate athletic training students. These increases were maintained at

seven- and l4-week retention testing.

Copyright by
JENNIFER LYNN STILLER

2008

This dissertation is dedicated to John, who made me realize that nothing in life that is

worth having comes easy.

ACKNOWLEDGEMENTS

This dissertation would not be complete without an acknowledgement of those
who have kept me sane and focused through this process. Thank you Dr. Dan Gould for
believing in me enough to bring me to Michigan State, and for your countless brilliant
ideas throughout my three years here. Your trust and faith gave me the confidence I
needed to compete this work. Sincere thanks to Dr. Tracey Covassin for being a mentor,
a confidant, and a friend. Your help, support, and dedication will never be forgotten. Of
course, huge thanks to my committee members, Dr. Crystal Branta and Dr. Marty Ewing,
whose insight helped make this a stronger study. You are two brilliantly intelligent
women and I am a stronger scholar, teacher, and person because of you.

I would also like to give special thanks to several individuals who played an
important part in the long road leading up to the completion of my PhD. To Dave
Csillan: you introduced me to this profession, and through your passion and commitment,
convinced me to follow in your footsteps — one of the best decisions I have ever made.
Thank you to my mentors at Salisbury University, Jay Scifers and Pat Lamboni, for
developing both my skills as an athletic trainer and my love for and dedication to the
profession. Thank you to the faculty and staff at the University of Kentucky, and to Dr.
Tim Uhl, for helping me to mature as a competent researcher. Of course, thank you to
my parents, Carole and Tom Stiller, who taught me to read, to challenge, and to love the
process. To AP, RE, and M.RF, thanks for the good times, the laughs. the inappropriate
jokes (and those laughs), the use of your TVs. the good meals, and your friendship.

Finally, thank you to John. who started this journey as a friend and ended as much more.

vi

TABLE OF CONTENTS

LIST OF TABLES ....................................................... x
LIST OF FIGURES .................................................... xiii
CHAPTER I INTRODUCTION ............................................ l
CHAPTER 2 REVIEW OF LITERATURE .................................... 7
Introduction ....................................................... 7
Communication and Interpersonal Skills ................................ 9
Academic Preparation of Athletic Trainers as Counselors ............ I I

Providing Social Support ..................................... 15

Use of Goal Setting to Facilitate Social Support ............. 21

Social Support from Similar Others ........................ 22

Sport Psychology in the Athletic Training Room ......................... 24
Psychological Skills Training Techniques ........................ 27

Stress Inoculation Training .............................. 28

Somatic (Physiological) Interventions ..................... 3]

Cognitive Based Interventions ........................... 32

Imagery in Rehabilitation ............................... 34

Cognitive-Somatic Interventions ......................... 38

Behavioral Interventions: Goal Setting ..................... 41

Applied Sport Psychology Course for Athletic Trainers ................... 44
Summary ........................................................ 46

Future Research Directions .................................... 48

CHAPTER 3 IDENTIFYING PSYCHOSOCIAL COMPETENCIES NEEDED BY

CERTIFEID ATHLETIC TRAINER .................................. 50
Background ...................................................... 50
Study 1: Athlete-Identified Strategies for Improving the Communication,
Motivation, and Social Support Skills of Athletic Trainers ........... 50
Method and Participants ...................................... 51
Results .................................................... 52
Communication and Athlete Education .................... 53
Motivation ........................................... 53
Social Support ........................................ 54
Discussion and Implications ................................... 54
Study 2: Recently Certified Athletic Trainers’ Perceptions of Essential
Psychosocial Components within Athletic Training Education ........ 55
Method and Participants ............................. . ........ 55
Results .................................................... 57
Discussion and Implications ................................... 58

vii

CHAPTER 4 DEVELOPING AND ASSESSING A COURSE DESIGNED TO
ENHANCE ATHLETIC TRAINING STUDENTS’ PSYCHOSOCIAL

COMPETENCIES ................................................ 60

Method ......................................................... 60

Participants ................................................ 60

Study Design ............................................... 61

The ASP-AT Educational Module .............................. 63

Instrumentation ............................................. 64

Questionnaire Development ............................. 64

Test Taking Schedule ........................................ 66

Data Analysis Plan .......................................... 68

Primary Analyses ..................................... 68

Secondary Analyses ................................... 76

Psychology of injury Transfer Survey ..................... 80

Exploratory Analyses .................................. 80

Summary .................................................. 87

CHAPTER 5 DISCUSSION ............................................... 88

Introduction ...................................................... 88

Overview of ASP-AT Module Content ................................ 88

Discussion of the Statistical Effectiveness of the ASP-AT Module ........... 95

Contribution to the Literature ....................................... 100

Conclusions ..................................................... 101

Participant Feedback and Pedagological Changes ....................... 103

Limitations ...................................................... 104

Future Research Directions ......................................... 105

APPENDIX A INTERVIEW GUIDE FOR STUDY 1 ......................... 109

APPENDIX B HUMAN SUBJECTS APPROVAL FOR STUDY 1 ............... 112
APPENDIX C ATHLETES’ COMMUNICATION, SOCIAL SUPPORT. AND

MOTIVATION EXPECTATIONS ............................ I 15

APPENDIX D HUMAN SUBJECTS APPROVAL FOR STUDY 2 .............. 120

APPENDIX E INTERVIEW GUIDE FOR STUDY 2 .......................... 123

APPENDIX F HUMAN SUBJECTS APPROVAL FOR DISSERTATION STUDY . 127

APPENDIX G APPLIED SPORT PSYCHOLOGY FOR ATHLETIC TRAINERS
COURSE CONTENT AND SCHEDULE ....................... I30

viii

APPENDIX H SURVEY DEVELOPMENT METHODS.

SURVEY PSYCHOMETRICS ..................................... 138
APPENDIX I ORIGINAL PSYCHOLOGY OF INJURY

USAGE SURVEY (POI—U) ........................................ 144
APPENDIX J ORIGINAL PSYCHOLOGY OF INJURY

TRANSFER SURVEY (POI-T) ..................................... 149
APPENDIX K FINAL PSYCHOLOGY OF INJURY

USAGE SURVEY (POI-U) ........................................ 155
APPENDIX L FINAL PSYCHOLOGY OF INJURY

TRANSFER SURVEY (POI—T) ..................................... 159
APPENDIX M PSYCHOLOGY OF INJURY KNOWLEDGE TEST (POI-K) ...... 163
APPENDIX N KEY TO PSYCHOLOGY OF INJURY KNOWLEDGE

TEST (POI-K) ................................................... 166
APPENDIX 0 RESULT TABLES FROM CHAPTER 4 ....................... 177

REFERENCES ........................................................ I96

LIST OF TABLES

Table 3.1. Athlete Participant Demographics .................................. 52
Table 3.2. Athletic Trainer Participant Demographics ........................... 57
Table 4.]. Athletic Training Room Characteristics ............................. 62
Table 4.2. Correlations of POI—K to POI-U Scores at Baseline, Week 3, and Week 6 . .71
Table 4.3. RMA Multivariate Output for POI-K ............................... 72
Table 4.4. RMA Tests of Within-Subjects Effects for POI-K ..................... 72
Table 4.5. RMA Multivariate Output for POI-U ............................... 74
Table 4.6. RMA Tests of Within-Subjects Effects for POI-U ..................... 74
Table 4.7. MANOVA Multivariate Output for POI-K and POI-U at Week 6 ......... 76
Table 4.8. MANOVA Univariate Output for POI-K and POI-U at Week 6 ........... 76
Table 4.9. RMA Multivariate Output for POI-K (Group B Change Over Time) ....... 77
Table 4.10. RMA Multivariate Output for POI-U (Group B Only) ................. 79
Table 4.1 1. RMA Tests of Within Subjects Effects for POI-U (Group B Only) ........ 79

Table 4.12. Dependent t-tests for Group B Control: Intervention POI-K and POI-U. . . .81

Table 4.13. Independent t-tests for POI—K and POI-U (all participants) ............. 84
Table 4.14. Independent t-tests (Undergraduate Participants Only) ................. 85
Table 4.15. Dependent t-tests for POI-K and POI-U Total (A and B Combined) ...... 86
Table C.1. Athletes’ Communication, Social Support, and Motivation Expectations . .1 15
Table H.I. Psychometrics for Psychology of Injury Transfer Survey (POI-T) ....... 142
Table H.2. Psychometrics for Psychology of Injury Usage Survey (POI-U) ......... 142
Table 0.1. Baseline and Follow-up POI-K Means and Standard Deviations for

Hypothesis 1 .............................................. I77

Table 0.2. Box M Test for Equality of Covariance Matrices from RMA ........... 177

Table 0.3. Levene’s Test of Equality of Error Variances from RMA .............. 177

Table 0.4. Mauchly’s Test of Sphericity from RMA for Hypothesis 1 ............. 178

Table 0.5. Baseline and Follow—up POI-K Means and Standard Deviations

(Undergraduate Students Only) ............................... 178

Table 0.6. RMA Multivariate Output for POI-K (Undergraduate Students Only) . . . . 178

Table 0.7. RMA Tests of Within-Subjects Effects for POI-K

(Undergraduate Students Only) ............................... 179
Table 0.8. Linear Trend Table (Tests of Within-Subjects Contrasts) .............. 179
Table 0.9. Group Pairwise Comparisons from Hypothesis 1 ..................... 180
Table 0.10. Time Pairwise Comparison from Hypothesis 1 ..................... 180
Table 0.1 l . Group A POI-U Subscales Change Due to Intervention .............. 181
Table 0.12. Baseline and Follow-up POI-U Means & Standard Deviations ......... 181
Table 0.13. Box M for Equality of Covariance Matrices from RMA .............. 182
Table 0.14. Levene‘s Test of Equality of Error Variances from RMA ............. 182
Table 0.15. Mauchly’s Test of Sphericity from RMA for Hypothesis 2 ............ 182
Table 0.16. Baseline and Follow-up POI-U Means and Standard Deviations

(Undergraduate Students Only) ............................... 182
Table 0.17. RMA Multivariate Output for POI-U (Undergraduate Participants Only) .183
Table 0.18. RMA Tests of Within-Subjects Effects for POI-U

(Undergraduate Participants 0nly) ............................. 183
Table 0.19. Linear Trend (Tests of Within-Subjects Contrasts) .................. 184
Table 0.20. Group Pairwise Comparisons from Hypothesis 2 .................... 184
Table 0.21 . Time Pairwise Comparisons from Hypothesis 2 .................... 184
Table 0.22. Group B POI-K Means & Standard Deviations (Hypothesis 3) ......... I85

xi

Table 0.23. Mauchly’s Test of Sphericity from RMA for Hypothesis 3 ............ 185

Table 0.24. Linear Trend (Tests of Within-Subjects Contrasts) .................. 185
Table 0.25. Time Pairwise Comparisons from Hypothesis 3 .................... 186
Table 0.26. Group B POI-U Subscale Change Due to Intervention ............... 187
Table 0.27. Group B POI-U Means & Standard Deviations (Hypothesis 4) ......... 187
Table 0.28. Mauchly’s Test of Sphericity from RMA for Hypothesis 4 ............ I 87

Table 0.29. Linear Trend (Tests of Within-Subjects Contrasts) from Hypothesis 4 . . .188
Table 0.30. Time Pairwise Comparisons from Hypothesis 4 .................... 188

Table 0.31 . Group B POI-K and POI-U Means and Standard Deviations for Control and
Intervention Periods ........................................ 189

Table 0.32. POI-K and POI—U Group Means & Standard Deviations (Hypothesis 9) . 189

Table 0.33. POI-K and POI-U Group Means & Standard Deviations for Hypothesis 9

(Undergraduate Participants Only) ............................. 190

Table 0.34. POI-K Paired Sample Statistics from Dependent t-tests for Groups A and B

Combined (Research Question 1) ................................ 190
Table 0.35. POI-U Paired Sample Statistics from Dependent t-tests for Groups

A and B Combined (Research Question I) ......................... 191
Table 0.36. Paired Sample Statistics from Dependent t-tests for Group A .......... 191
Table 0.37. Dependent t-tests for POI-K and POI-U Total (Group A Only) ......... 192
Table 0.38. Paired Sample Statistics from Dependent t-tests for Group B .......... 193
Table 0.39. Dependent t—tests for POI-K and POI-U Total (Group B Only) ......... 194

xii

LIST OF FIGURES

Figure 4.1. Study Design and Assessment Timeline ............................. 70
Figure 4.2. Group and Time Interactions for POI-K ............................. 73
Figure 4.3. Time Interaction for POI-U ....................................... 75
Figure 4.4. Trend Analysis for POI—K (Group B only) ........................... 78
Figure 4.5. Trend Analysis for POI-U (Group B only) ........................... 80

xiii

CHAPTER I

Introduction

The professional success of certified athletic trainers (ATCs) is influenced by
more than the ability to provide effective physical interventions to injured athletes.
Specifically, increasing attention is being placed on the importance of psychological
recovery from athletic injury. Athletic Training Education Programs (ATEPs) generally
focus primarily on the physical nature of athletic injury, and for good reason. The
primary roles of ATCs include physical injury prevention, evaluation and treatment, and
rehabilitation. However, the National Athletic Trainers’ Association Board of
Certification and the Education Council agree that knowledge regarding psychology of
injury is also essential for the entry-level ATC. This is evidenced by the inclusion of
Psychosocial Intervention and Referral as one of 12 content areas required in accredited
ATEPs.

Although the Commission on Accreditation of Athletic Training Education
(CAATE) standards now require formal instruction in psychology, they make no
suggestions or requirements regarding how such competencies must be taught. While
this has the benefit of allowing ATEPs to implement these competencies in any way that
they choose, it may be a detriment to athletic training students. Competency guidelines
provided to ATEPs are very general, and there is a need for educational preparation
regarding specific, practical application of psychology of injury knowledge. Effective
interpersonal skills (e.g., communication, social support, motivation) and sport
psychology skills (e.g., relaxation, imagery, self-talk) are not generally a primary focus

during athletic training education; rather these skills are expected to develop from gaining

experience throughout one’s professional career. The absence of a CAATE—required
course in sport psychology leaves the placement and development of the Psychosocial
Intervention and Referral competencies to the discretion of the individual ATEPs. This
may put newly certified athletic trainers, and the athletes served by this population, at a
disadvantage.

Previous research indicates that many ATCs feel underprepared by their ATEPs
to handle situations within these content areas (Misasi, et a1., 1996; Misasi, 1998).
Additionally, survey research has indicated that the use of techniques such as imagery,
relaxation, and self-talk in the athletic training room would likely be increased if ATCs
had a stronger knowledge base in this area (Weise, Weiss, & Yukelson, 1991).
Unfortunately, these results were published in 1991 (over 15 years ago), prior to the
elimination of the internship route to certification and prior to the mandated inclusion of
education in psychosocial intervention and referral. It is necessary to determine if the
need for this knowledge is being met by current educational standards within ATEPs.
Research must be conducted with recently certified ATCs in which the academic
preparation and early professional experiences in the areas of communication,
motivation, social support, and psychological skills training (PST) techniques are
evaluated. With the growing body of research on psychology of injury, there may also be
a need to expand education on psychology of injury within the content area of
psychosocial intervention. Currently, the area of psychology of injury is given equal
weight as other psychological issues (e.g., eating disorders, depression); however, issues
requiring communication skills and motivational strategies are more common than these

other psychological issues (S. P. Pero, Covassin, & O'Neil, 2000) and less likely to

 

require advanced referral. ATCs will be expected to handle such issues, and they need
the appropriate skill set to do so.

This dissertation has two primary purposes: (a) to determine what psychosocial
competencies certified athletic trainers need to be taught during their education programs;
and (b) to determine whether the Applied Sport Psychology for Athletic Trainers
educational intervention module is effective at increasing athletic training students’
(ATS) knowledge in psychology of injury and their ability to apply knowledge to real-
world situations with injured athletes in the athletic training room. It is comprised of
three studies with one comprehensive review of literature (Chapter 2). Chapter 3
addresses Purpose 1 and encompasses two background research studies that established
the need for the primary study contained in this dissertation (Chapter 4). The first
background study involved currently or previously injured collegiate student-athletes, the
purpose of which was to identify important psychosocial aspects of the athlete-athletic
trainer relationship as perceived by this population. The second background study
involved recently certified athletic trainers. The purpose of this study was to assess the
relevant psychosocial issues that newly certified ATCs face, and the extent to which their
undergraduate education prepared them to handle these issues. The combined goal of
these background studies was to triangulate information gained from the literature,
injured athletes, and ATCs to generate a list of psychosocial content to be included in
ATEPs. Chapter 4 addresses the second purpose and contains an evaluation of the
effectiveness of a new educational module focused on applied sport psychology for
athletic trainers. This chapter also contains a discussion of the development of two
psychometrically sound questionnaires designed to measure the application and transfer

of sport psychology knowledge and applied sport psychology techniques to the athletic
3

training room. The following hypotheses and research questions were examined in this
study:
Primary Hypotheses:

H 1: Intervention Group A will demonstrate increased psychology of injury
knowledge after a 6-week educational module versus a Control Group. as measured by
the Psychology of Injury Knowledge Test (POI-K).

H2: Intervention Group A will demonstrate increased usage of psychology of injury
techniques after a 6—week educational module versus a Control Group, as measured by
the Psychology of Injury Usage Survey (POI-U).

Secondary Hypotheses:

H3: Intervention Group B will demonstrate increased psychology of injury
knowledge after a 6-week educational module versus its own control period, as measured
by the POI-K.

H4: Intervention Group B will demonstrate increased usage of psychology of injury
techniques after a 6—week educational module versus its own control period, as measured
by the POI-U.

H5: There are no differences between athletic training student and athlete perceptions
of frequency of use of psychology of injury techniques in the athletic training room, as
measured by differences between the POI-U and the Psychology of Injury Transfer

Survey (POI-T).

Exploratory Hypotheses:

H6: Student-athletes working with participants in Intervention Group A will report
increased frequency of use of psychology of injury techniques versus student-athletes
working with participants in the Control Group, as measured by the POI-T.

H7: Student-athletes working with participants in Intervention Group B will report
increased frequency of use of psychology of injury techniques as compared to the use by
participants during the control period, as measured by the POI-T.

H8a: Intervention Group B will demonstrate increased psychology of injury
knowledge after Week 3 of the educational module versus knowledge at Week 3 of the
control period, as measured by the POI-K.

H8b: Intervention Group B will demonstrate increased psychology of injury
knowledge after Week 6 of the educational module versus knowledge at Week 6 of the
control period, as measured by the POI-K.

H8c: Intervention Group B will demonstrate increased psychology of injury technique
usage after Week 3 of the educational module versus technique usage at Week 3 of the
control period, as measured by the POI-U.

H8d: Intervention Group B will demonstrate increased psychology of injury
technique usage after Week 6 of the educational module versus technique usage at Week
6 of the control period.

H9a: Intervention Groups A and B will demonstrate no differences in psychology of
injury knowledge after Week 3 of the educational intervention. as measured by the
POI-K.

H9b: Intervention Groups A and B will demonstrate no differences in psychology of

injury knowledge after Week 6 of the educational intervention. as measured by the

5

POI-K.

H9c: Intervention Groups A and B will demonstrate no differences in psychology of
injury technique usage after Week 3 of the educational intervention, as measured by the
POI-U.

H9d: Intervention Groups A and B will demonstrate no differences in psychology of
injury technique usage after Week 6 of the educational intervention, as measured by the
POI-U.

Exploratory (Non—Directional) Research Question:
RQI: What percentage of psychology of injury knowledge do participants retain

following the end of the Intervention period?

CHAPTER 2

Review of Literature
Introduction

With the growth of athletic participation over recent decades, athletic injury has
become a major risk for athletes competing at all levels and in all sports. Regardless of
sex, an athlete has a 50% chance of becoming injured (Arnheim & Prentice, I993;
Beachy, Akau, Martinson, & Olderr, 1997). In any single year, one in six athletes will
sustain an athletic injury serious enough to cause missed athletic participation (Ballard,
1996). Along with this growth in athletic participation and subsequent injury has come
an increased recognition of the need for ATCs and other sports medicine professionals to
provide care for injured athletes. Until the 19905, rehabilitative interventions primarily
addressed the physical dimensions of sports injury, focusing on helping athletes return to
pre-injury level of function by treating the obvious physical symptoms (Van Heerden &
Potgieter, 2003). However, pain is both physical and psychological, and often
overlooked in the injury treatment and rehabilitation processes is the emotional
component and the role of the mind (Lynch, 1988). Pain does not occur in the body
without the mind reacting and contributing to the experience (O'Connor. 2002). Thus, it
would seem that the treatment of physical symptoms is only half of the solution, because
the athletic injury involves strong emotional and mental components.

Due to frequent contact with injured athletes during recovery and rehabilitation,
ATCs are in a position to provide psychological skills training and emotional support to
their athletes (Van Heerden & Potgieter, 2003). Key sport psychology topics that have

been suggested to be components of an athletic injury rehabilitation program include

effective communication and motivation skills, social support and counseling, cognitive
restructuring, imagery, relaxation, and goal setting. “A holistically educated and skilled
[athletic trainerl is in an excellent position to provide effective social support for injured
athletes which will facilitate optimal recovery” (Ford & Gordon, 1993). Results of a
national survey of ATCs indicated that 47% believe that athletic injuries affect athletes
both psychologically and physiologically, and most believe that both psychological and
physiological factors need to be addressed during rehabilitation (Larson, Starkey, &
Zaichkowsky, I996). Athletic trainers have experience-based knowledge about
psychological responses to injury but often lack systematic and specific educational
preparation in these areas (Wiese-Bjornstal & Smith, 1993). A need and desire for more
formal education or continuing education on the psychological factors and strategies
associated with the rehabilitation from athletic injury has been communicated by ATCs
(Moulton, Molstad, & Turner, 1997; Weise et a1., 1991).

While 70% of certified athletic trainers hold advanced degrees (Association,
2006), there is little documentation that they receive graduate courses related to
psychology and counseling (Pennsylvania, 1998). The undergraduate setting is the ideal
location for such a course, as this placement would ensure that all ATCs who have met
entry-level standards have had formal education and have demonstrated competency in
this content area. This review will discuss the components deemed to be essential
inclusions in a course on applied sport psychology and counseling for athletic trainers.
with research justifications for each component. Areas that will be discussed include:
communication and interpersonal skills; counseling and social support: relaxation,

imagery. self-talk, and goal-setting.

Communication and Interpersonal Skills

Communication and interpersonal skills are critical for any professional in the
allied health fields. These professionals must put clients at ease, often in very scary and
uncertain situations. Professionals must be good listeners to help identify symptoms, and
must be excellent communicators with the ability to translate complex medical
information into terms that can be easily understood by patients. As communication
skills become more and more important in the allied health fields, it is essential to
determine what type of communication athletes respond to and what skills to incorporate
into an athletic training curriculum. Communication should be embedded in a global
patient-oriented curriculum, as communication skills are viewed as core elements of good
medicine (Deveugele et a1., 2005). While there is no gold standard for good
communication between health care provider and patient, emphasis on patients’ ideas,
concerns, emotions, and need for information are key. In athletic training, listening skills
are needed in order to allow athletes to fully express themselves, to explain their injury,
and to ask questions about what to expect over the course of their injury. Clear,
controlled communication is the primary responsibility of athletic trainers during initial
management of injury (Wiese-Bjomstal & Smith, 1993). Communication skills are also
essential for an ATC to provide social support to the athlete, and to ensure athlete
adherence and compliance during injury rehabilitation. There is evidence in the medical
field that good doctor-patient communication is related to better outcomes, better
compliance, and higher satisfaction of both doctor and patient (Brown, Stewart. & Ryan,
2003; Stewart et a1., 1999).

A two-part study published in 1993 examined what factors athletes and ATCs

considered important when relating to athletes who are injured or rehabilitating (Fisher &

9

Hoisington, 1993; Fisher, Mullins, & Frye, l993b). Thirty-six athletes and 187 ATCs
responded to Likert scales and open-ended questions. Data analysis yielded the
following factors as being important by both ATCs and athletes: good rapport and
communication between ATC and injured athlete; clear explanation of the injury and the
rehabilitation regimen; athlete motivation; and support from important others. Athletes in
this study also identified successful rehabilitation and adherence strategies that are used
or should be used by ATCs. Strategies included clarifying expectations about the
rehabilitation process, goal setting and motivation, progress monitoring, and personalized
treatment (Fisher & Hoisington, 1993). Similar results were reported from preliminary
interviews with 13 injured athletes (Ford & Gordon, 1993). These athletes indicated that
an improvement in communication skills was needed, with suggestions that ATCs ensure
that athletes are aware of what is occurring at all stages of rehabilitation, provide candid
information in a language that athletes can understand, and encourage athletes to discuss
matters that are concerning (Ford & Gordon, 1993).

In a more recent study (Stiller, Gould, Paule, & Ostrowski, 2006), in-depth
interviews were conducted with nine previously and currently injured collegiate athletes.
These interviews focused on the relationship between athletes and their ATCs.
Qualitative content analyses of these interviews suggest that the majority of traits that
athletes perceive as being negative center around communication and interpersonal
issues. Athletes complained about ATCs who “hide out” in their offices rather than
staying in the athletic training room and talking with athletes during treatments and
rehabilitation. Positive traits centered on good communication, ability to explain injuries
and treatments in Ian guage that athletes could understand, and positive personal

relationships between ATCs and athletes. More specifically, athletes identified the

10

following general qualities of effective ATCs: motivating and challenging; confident and
experienced; attentive and accommodating; informative and helpful; friendly and
relatable; and having positive personality traits. Personality traits that made the
rehabilitation experience more enjoyable included having a positive attitude and being
out-going, trustworthy, genuine, passionate, and comforting. (Stiller, Gould, Paule et a1.,
2006).

In summary, when an injury occurs, athletes will likely listen and adhere to what
is suggested or advocated by ATCs if a personal relationship has already been established
(Shelley, Trowbridge, & Betling, 2003). Athletic training students need education and
practice in communication prior to entering the professional world. With the types of
communication that athletes prefer and respond to identified, the next step is to
incorporate training in these skills into athletic training undergraduate curriculum
programs.

Academic Preparation of Athletic Trainers as Counselors.

Many athletic programs do not have mental health professionals available full-
time, which often makes the ATC the first point of contact for athletes dealing with the
emotional or psychological issues associated with injury. Successful development of the
relationship between the ATC and athlete depends on the environment of the athletic
training room and on the informal counseling skills of the ATCs themselves (S. P.
Misasi, Kemler, & Redmond, I998a). Attending to athletes, active listening,
paraphrasing, and reflecting can be considered communication skills, but are better
regarded as counseling skills when the athlete sets the agenda of the dialogue. The ATC
should develop these counseling skills to facilitate self-expression and autonomy on

behalf of the athlete (Rock & Jones, 2002).

II

Counseling is not the principle function of ATCs, but it is an important aspect of
their professional role (Fumey & Patton, 1985). The term ‘counseling’ is used differently
in different contexts. By definition, a counselor is someone who helps an individual find
answers and resolutions to issues by guiding these individuals in making informed, sound
choices (George & Cristiani, 1986). Counseling injured athletes involves educatinO.
establishing rapport and communication, and providing “emotional first aid” (Rock &
Jones, 2002). Some professionals follow specific preparation for their work in
counseling and are awarded credentials or licenses in counseling; other professionals, like
athletic trainers, are considered informal counselors due to their day-to—day interactions
with individuals seeking their assistance (S. P. Misasi et a1., I998a). Counseling skills
are defined as “competency or accomplishment in communication, acquired or developed
in training” (Culley, 1993). Athletic trainers are not professionally trained counselors
and, although academic curriculum should provide ATCs with some degree of
preparation for this role, often we find that this is not the case. It should also be noted
that all athletic training programs should have licensed counselors or psychologists
available for referral, and that ATCs should know when and how to make referral to a
licensed mental health professional.

To evaluate the extent to which ATCs function in a counseling role, a survey was
sent to 500 randomly selected ATCs who were certified in either 1997 or 1998, as these
athletic trainers would have been required to complete competencies in the area of
psychology of injury. 0f the 139 ATCs who responded, 90% indicated that they counsel
athletes regarding injury—related problems, 77% counsel athletes regarding sport-related

problems, and 65% counsel athletes regarding personal problems. Despite the frequency

12

with which ATCs report counseling as a vital part of their job, 60% felt that they were not
adequately trained in counseling (S. P. Pero et a1., 2000).

A series of research studies conducted at two Connecticut universities have
demonstrated through survey research that most ATCs (70-85%) feel academically
prepared to counsel in the areas of injury prevention, injury rehabilitation, and nutrition
(S. Misasi, Davis, Morin, & Stockman, I996). Correspondingly, these are the top three
areas that ATCs reported clinical experience in counseling athletes. However, these
studies Confirmed results of previous studies in that ATCs felt unprepared or under-
prepared to detect, to counsel, and to make referrals in psychological areas such as
alcohol, drug use and abuse, relationship issues, sexual issues, suicide, family matters,
racial issues, and financial issues (S. Misasi et a1., 1996; S. P. Misasi, I998). Across all
areas of psychological counseling, the majority of ATCs indicated that more emphasis
should be placed on counseling during academic preparation (S. Misasi et a1., 1996).
Survey results also indicated that athletic training coursework is severely lacking in the
amount of psychology courses that are offered or required (S. P. Misasi, 1998).

It has been hypothesized that individualized and direct personal counseling during
the rehabilitation process is important, and that intervention strategies that focus on
communication and listening skills help athletes in their search for meaning in their
injury experience (Ermler & Thomas, 1990). A counseling intervention with three
injured athletes has been shown to produce high adherence to rehabilitation (Rock &
Jones, 2002). Additionally, athletes participating in the program identified members of
the sports medicine team, and ATCs in particular, as important sources of information
support. Specifically, injured athletes valued information about the injury, surgical

intervention, and the course of rehabilitation. Despite the limited number of subjects, this

13

study demonstrates that counseling intervention has potential to provide emotional,
listening, and information support. While it is likely impractical to recommend
implementing such an intervention with all athletes due to time constraints, it may be
useful during rehabilitation setbacks.

Injured athletes need an outlet to discuss concerns privately, apart from
individuals who have a vested interest in their expedient return to sport (B. W. Brewer,
Jeffers, Petitpas, & Van Raalte, 1994). Many researchers agree that “counselor” is a vital
role played by athletic trainers and argue that more curriculum offerings and advanced
instruction should be provided (Fields, Murphey, Horodyski, & Stopka, 1995: Furney &
Patton, 1985). Dozens of studies indicate that while athletic trainers feel that this issue of
counseling is important, they lack knowledge about how to act as an informal counselor
(Anderson & Hill, 1995; Compton & Ferrante, I991; Elmer & Thomas, 1990; Furney &
Patton, 1985; Gieck, 1994; S. Gordon, D. Milios, & J. R. Grove, 1991; Henderson &
Carroll, 1993; Kane, 1982, 1984; S. Misasi et al., 1996; Pedersen, 1986; Rotella, 1985;
Tuffy, 1991; Tunick, Etzel, & Leard, 1991; Weise et a1., 1991; Weiss & Troxel, 1986;
Zeske, 1994). Practical counseling suggestions for ATCs are offered in several research
publications (S. P. Misasi et a1., I998a; Shelley et a1., 2003), but professional preparation
of the role of a counselor is currently lacking in athletic training education programs.
There is a demand for counseling professionals to be sensitive to athletes (Hinkle, 1991);
therefore it stands to reason that there is a need for professionals who care for athletes to
be sensitive to psychological and counseling issues. To this extent, instruction in injury
and non-clinical psychological counseling should be considered essential elements of

athletic training education programs.

14

It should be noted, however, that while athletic trainers need to develop
appropriate counseling skills and a counseling mindset, the counseling field is a highly
specialized profession that has its own certification and standards. While it is important
for ATCs to become better prepared as counselors, it is in no way implied that they will
be equivalent to professional counselors in these skills and competencies. In addition to
developing communication and counseling skills, ATCs must develop a referral protocol
that will be followed when they are confronted with issues outside of their experience or
training.

Providing Social Support.

Social support can be defined as an exchange of resources between at least two
individuals perceived by the provider or the recipient to be intended to enhance the well-
being of the recipient (Shumaker & Brownell, 1984). Social support has been proposed to
reduce stress and improve psychological and physical health in injured athletes primarily
through the buffering hypothesis, which states that social support buffers the impact of
stress on the individual, indirectly affecting the individual’s well-being. When social
support is low, the relationship between stress and psychological and physical well-being
is strong and direct. When social support increases, stress and well-being are no longer
correlated (Hardy, Richman, & Rosenfeld, 1991; House, 1981). To this extent, providing
social support to all athletes may serve to prevent the occurrence of injury (Udry, 1996).
Several studies have also demonstrated a positive effect of social support on
psychological distress following athletic injury (Cobb, 1976; Duda, Smart, & Tappe,
1989; Gordon & Lindgren, 1990; Ievleva & Orlick, 1991). Social support, then, is a

variable that may play a significant role in both etiology and recovery from athletic

15

injury, with quality of social support being more important than quantity of providers
(Udry, 1996).

There are eight broad categories of social support: listening support, emotional
support, emotional challenge, task appreciation, task challenge, reality confirmation,
personal assistance, and tangible assistance (Richman, Rosenfeld, & Hardy, 1993).
Categories of social support are not necessarily mutually exclusive and are not provided
in isolation (Richman, Hardy, Rosenfeld, & Callahan, 1989). Because individuals
generally require a combination of support types, the eight broad categories are often
grouped into three dimensions: emotional support (listening support, emotional support,
emotional challenge); information support (reality confirmation, task appreciation, task
challenge); and material support (personal and tangible assistance) (Rock & Jones, 2002).
Listening support involves actively listening without giving advice or making judgments.
Emotional support is characterized by the willingness to provide support and comfort,
indicating that the provider is on the athlete’s side. Emotional challenge involves
challenging the athlete to evaluate attitudes, values, and feelings in an effort to overcome
obstacles and achieve goals. Reality confirmation, sometimes referred to as shared
social reality, refers to having someone who is similar to the athlete available to offer
advice during times of confusion and stress and to confirm the athlete’s perspective of the
world. Task appreciation indicates acknowledgement of athlete effort and expressing
appreciation for high-quality work. Task challenge is characterized by consistent
challenge of the athlete’s way of thinking about a task of an activity in order to stretch,
motivate, and lead the support recipient to achieve more. Tangible assistance refers to
the provision of financial assistance, products, or gifts; personal assistance indicates
provision of services or help, such as running an errand or driving the support recipient

I6

somewhere (Ford & Gordon, 1993; Rosenfeld, Richman, & Hardy, 1989; Udry, 1996).
The social support network of college athletes can be divided into two broad categories:
support that requires content expertise (task appreciation and task challenge); and support
not requiring content expertise (listening support, emotional support, emotional
challenge, reality confirmation) (Rosenfeld et a1., 1989).

Research in the area of social support and injury recovery has been driven by two
major forces: recognition of the need for psychosocial intervention in sports injury
rehabilitation; and belief that the positive relationship between social support and
improved recovery outcomes observed in non-sport populations can be extended to sport
populations (Hardy & Crace, 1993). In research on exercise adherence, the variable
contributing most of the difference between adherers and non—adherers was the amount of
encouragement perceived from supervisors and others in the program. This is consistent
with previous reports that individuals who do exercise prefer to do it with at least one
other (Willis & Campbell, 1992). Reports in the general medical field have indicated that
social support enhances recovery from illness if the support is appropriate and from the
right source (Schaefcr, Coyne, & Lazarus, 1981; S. Taylor. 1986; Wallston, Alagna,
DeVellis, & DeVellis, 1983). Lack of social support was the single most important
predictor of non-compliance in cardiac rehabilitation (Oldridge, 1984). Fisher (1993)
found the same result with adherence among injured athletes, although there is some
criticism that the adherence measure used was not psychometrically sound (Fisher,
Scriber, Matheny, Alderman, & Bitting, 1993). Nevertheless, the implications of these
research findings to injury rehabilitation are clear: athletes may be more likely to adhere
when they receive support and encouragement from their ATC. Further. matching
injured athletes with other athletes rehabilitating similar injuries may increase

17

commitment to the program and motivation to work hard. However, generalizations from
exercise adherence and cardiac rehabilitation studies cannot be readily made to injured
athletes due to the difference in population characteristics. Rather, success in these
related areas provide a basis for expanding social support research to injured athletes. In
doing so, it is important to delineate what types of social support facilitate adherence to
injury rehabilitation protocols (Hardy & Crace, 1993). Injured athletes need social
support from four main sources: family, friends, and significant others; coaches and
teammates; athletic trainers and the sports medicine team; and similar others (i.e., other
injured athletes). Because the purpose of this dissertation is to develop an applied course
for athletic trainers, this review is focused on social support from ATCs.

Research studies have demonstrated that athletes look increasingly towards
athletic trainers as a source of social support during the rehabilitation process (Hartman,
1999; Robbins & Rosenfeld, 2001 ), and that adherence to and compliance with
rehabilitation is positively related to injured athletes’ social support (Duda et a1., 1989;
Fisher, Domm, & Wuest, 1988). Further, in athletes who perceive their injury to be
severe, beliefs about the effectiveness of the rehabilitation program can be influenced by
the amount of social support that is perceived to be available (Bone & Fry, 2006).
Research is equivocal regarding the relationship between social support and various
positive rehabilitation outcomes with a shift towards the consensus that high social
support acts as a moderator in the life stress-injury relationship (i.e., the Buffering
Hypothesis). By tempering this relationship, social support may lead to decreased risk of
injury, decreased stress, and increased recovery rate following injury (S. Cohen & Wills,

1985; T. A. Petrie, 1992, 1993; Smith, Smoll, & Ptacek, 1990).

18

-'.In:

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1':

 

Social support received and expected by athletes was assessed in 57 collegiate
athletes via the Social Support Survey, a valid measure with sound psychometric
properties (Richman et a1., 1993). This study found listening support and task
appreciation to be the top two types of social support, and tangible assistant to be least
important (Bone & Fry, 2006). These results support findings of previous research using
the Social Support Survey (Barefield & McCallister, 1997). Here. athletes reported
receiving mostly listening support and task appreciation, and that these were the two
forms of social support that they expected from their athletic trainers (Barefield &
McCallister, 1997). They also reported receiving and expecting the least amounts of
tangible support and personal assistance. Specifically, athletes needed and expected the
athletic trainer to take time to listen and show empathy (emotional support dimension).
the need to know that the exercises are effective (information support), the need to feel
that accomplishments during injury rehabilitation are appreciated and that others
understand what they are going through (task appreciation), and the need to be pushed to
succeed in their rehabilitation (task challenge) (Barefield & McCallister, 1997). The
important findings relate to the athletes’ expectations, versus what was received, because
expectations often arise from athletes’ needs. It is important to note that social support
perceived by athletes is more important than social support actually received. The
implication of this is that ATCs’ attitudes and presence should be such that athletes feel
welcome to approach the ATC for social support, with the expectation that provision of
support may not be required (Sarason, Sarason, & Pierce, 1990).

Examinations of the changing need for social support over time indicate that
needs for emotional support and material support dimensions decreased over time, while
the need for the information support dimension increased (Johnston & Carroll. 1998).

I9

Throughout the injury and rehabilitation process practical support was expected as
needed, based on the severity of the injury and disability. As rehabilitation progressed,
the early need for listening support and reality confirmation shifts to the need for
information support during middle and end stages of rehabilitation. Specifically. athletes
initially expect ATCs to function as an “information bridge” between the athlete and the
physician (Johnston & Carroll, 1998). Qualitative analysis of athlete comments indicated
that athletes considered it vital to have as much information as possible about their injury,
even though this information is likely to be emotionally painful (Johnston & Carroll,
1998). To this extent, the need for emotional support is at its peak during early
rehabilitation. Such support can only be provided by people with close personal
relationships with the athlete. When the ATC is considered one such individual, he or
she can help the athlete acknowledge the existence and severity of the injury (acute or
chronic), help choose treatment options, and assist athletes in rationalizing and
expressing thoughts and feelings. As rehabilitation progressed, the need for emotional
support was only paramount during “crisis periods,” such as setbacks or perceived lack of
forward progress. As the need for emotional support faded, needs shifted to include
information regarding rehabilitation progress, treatment-related advice, encouragement,
and motivation. Emotional support was again needed as the athlete prepared to return to
sport, with the expectation that the ATC would help athletes come to terms with anxiety
and other emotional reactions towards return (Johnston & Carroll, 1998).

Social support received has also been tied to perceived susceptibility of re-injury
(Bone & Fry, 2006). It has been reported that perceived susceptibility was uniquely
influenced by task challenge, in that athletes who were challenged by ATCs during
rehabilitation had increased belief in their ability to overcome injury and decreased fear

20

of being re-injured. It appears that when ATCs challenge athletes with harder, more
sport-specific tasks, athletes’ belief in the effectiveness and success of their rehabilitation
program escalates (Bone & Fry, 2006).

An interesting finding was that athletes’ self-presentation style may have an
influence on the social support and attention provided by ATCs, meaning that athletes
may have difficulty gaining the assistance they need because of the way they behave
(Silver, Wortman, & Crofton, 1990). Athletes who take steps to alleviate stressors but
who discuss distress they cannot handle on their own put themselves in an excellent
position to receive support from ATCs and others. However, athletes who suppress
distress by giving the impression that everything is fine despite stressful aspects of injury
or by conveying no information about their feelings may not signal a need for distress.
Conversely, injured athletes who constantly complain about their difficulties and only
focus on the negative may cause ATCs to feel inadequate in their ability to help the
athlete. These outward appearances do not necessarily reflect internal thoughts or needs
for social support. therefore ATCs should learn to recognize introverted styles and probe
to see if a need for support exists below this exterior (Silver et a1., 1990). One should
keep in mind, however, that over-support can be just as unhelpful as lack of support
(Coyne, Ellard, & Smith, 1990). It is important to recognize that there are situations in
which support may not always be welcomed or needed. For these reasons, it is important
for ATCs to develop an understanding of the athlete’s personality and aspects of the
situation.

Use of Goal Setting to Facilitate Social Support. Athletic trainers are in a unique
position to provide social support to injured athletes because of their familiarity with the
athlete, the sport. and the injury. Athletic trainers can provide support and give advice on

21

a daily basis throughout the rehabilitation process; however, one should not confuse
merely interacting with another as being the same as providing social support. Quality
social support does not occur automatically in an athlete’s environment, but rather it
needs to be purposefully developed (Richman et a1., 1989). Specific research on the
influence of structured goal setting by ATCs on perceived social support has been
conducted at Western Illinois University (Hartman, 1999, 2001). Results indicated that
ATCs are considered by athletes to be a source of social support only if the ATC
participates in both the goal-setting and physical rehabilitation processes. However, this
research suggests that, in general, ATCs are not educated about how to assist athletes in
developing specific, challenging, realistic, short-term goals. Goal setting and other
psychological skills have been suggested as effective means of improving the provision
of social support, with survey research indicating that professionals would welcome
further education and training in applied sport psychology (Ford & Gordon, 1993). Goal
setting and other relevant psychological skills are discussed in a subsequent section.
Social Support from Similar Others: Support Groups and Modeling. Participation
in injured athlete support groups led by ATCs or sport psychologists functions to
decrease injured athletes’ anxiety, and to increase motivation, sense of control, and self-
confidence (Barefield & McCallister, 1997; Ford & Gordon, 1993; Udry, 1997). Support
group counseling provides an opportunity for injured athletes to learn that they are not
alone in being injured and to benefit from the experiences of others with similar concerns
(Singer & Johnson, 1987; Weise & Weiss, 1987; Weiss & Troxel, 1986). Support
networks allow injured athletes to express fears, doubts, worries, frustrations, and
concerns to others who are empathetic. As the facilitator, it is important to remember
that these group discussions should not become “gripe sessions.” Discussions should

22

remain positive and focused on individual strengths and on factors that are controllable.
The dynamic of the session should be to empower, support, and encourage one another
toward overcoming apprehension and anxiety about the future (Shelley et a1., 2003).

Modeling is another technique for helping injured athletes. In one scenario, two
athletes who have sustained similar injuries and are rehabilitating concurrently are
matched. This provides both athletes with the opportunity to express fears and
frustrations, and to share in successes with another with similar experiences. This may
also serve to increase commitment to the rehabilitation program and increase motivation
to work harder (Bianco, 2001). Matching athletes with similar others who have
successfully completed injury rehabilitation and return to play following a similar injury
may also be helpful to demonstrate to the athlete that successful return to sport is
possible. This type of matching provides the athlete with a resource who can answer
questions about what the athlete can expect throughout injury and recovery. Qualitative
research with 10 elite downhill skiers who had recovered from serious sports injuries has
indicated that having a ‘rehabilitation buddy’ was motivational and challenging. Athletes
recalled drawing inspiration from comparing themselves to similar others, as this served
as a marker of their own rehabilitation process (Bianco, 2001).

The effectiveness of a modeling intervention was evaluated in a population of
female athletes rehabilitating from surgical repair of atom anterior cruciate ligament
(Flint, 1991). Twenty injured athletes were divided into modeling and control groups.
Individuals in the modeling group were age-matched with female models and this group
watched videotapes of basketball players going through rehabilitation or who had

recovered from surgery. Models emphasized dealing with rehabilitation by being

23

positive and anticipating a return to sport. Results indicated that the modeling group
demonstrated greater adherence to rehabilitation than did the control group (Flint, 1991).

These research findings accentuate the importance of athletic trainers providing
athletes with both physical and mental assistance to enable athletes to get through the
rehabilitation process as quickly and painlessly as possible. Although proof of a direct
relationship between social support and rehabilitation adherence or positive rehabilitation
outcomes has not been demonstrated consistently, there is a large enough body of
evidence to suggest potential and to recommend provision of social support to injured
athletes by ATCs. Research has identified aspects of social support that are best provided
by ATCs, as well as demonstrated the importance of receiving these types of support to
the recovery process of injured athletes. Data suggest what types of social support
athletes expect and receive, even breaking this down into timeframes. Additionally, goal
setting, injured athletes support groups, and peer modeling techniques are all effective at
increasing opportunities for facilitating social support provision from similar others,
increasing athlete motivation and adherence, and decreasing anxiety. The next step is to
educate ATS on the situations in which social support is appropriate and on practical
methods of providing social support. Additionally, it is critical to determine if such
educational intervention is effective.

Sport Psychology in the Athletic Training Room

Recently, sport psychologists and other professionals within allied health fields
have been interested in whether injured athletes could be taught to transfer and use
psychological skills learned in sport to injury rehabilitation settings. Of particular interest
to this review were the perceptions of ATCs about the use of sport psychology in the
athletic training room, as well as the research on use of PST with injured athletes. A

24

1991 study designed to evaluate the importance of sport psychology skills in the athletic
training room focused on the perceptions of certified and student athletic trainers (Weise
et a1., 1991). Athletic trainers in this study believed that focusing on short-term goals and
encouraging positive self-thoughts were effective psychological techniques for
facilitating athletes’ injury recovery. The study was replicated in 2000 with 57
Australian physiotherapists (Francis, Anderson, & Maley, 2000). There was agreement
across both studies, with ATCs and physiotherapists rating practical strategies such as
communication, social support, and reinforcement as most important. Psychological
skills such as relaxation, mental imagery, and concentration development were ranked
less important. One explanation for this finding was that while ATCs are familiar with
psychological skills, they may believe that injured athletes would not benefit from them
or that athletes would be resistant to their implementation. Another possibility was that
while ATCs may believe in the use of these techniques, they may not feel qualified to
implement them, and therefore ranked them as less important. Both of these explanations
stemmed from one main problem: education, or rather, lack of education. An alternative
explanation was that psychological skills require some specific instruction by the ATC
and practice by the athletes, unlike the first three which are utilized and controlled by the
ATC only.

Although some studies have indicated that ATCs view psychological skills as less
important in injury rehabilitation, other studies have shown these skills to be extremely
important to successful recovery and rehabilitation. The Athletic Trainer and Sport
Psychology Questionnaire (ATSPQ) was developed for use in this line of research
(Larson et a1., 1996). Questions focused on behaviors associated with successful and
unsuccessful coping with athletic injury, frequency of use of psychological skills with

25

athletes during injury, rating of the importance of using and learning about psychological
skills and techniques in relation to athletic injury, rating of the importance of the
psychological aspect of athletic injury, and importance of a course in sport psychology in
the education of an athletic trainer. The ATSPQ was modified in 2002 to be used with
sport physiotherapists in the United Kingdom (Hemmings & Povey, 2002). Because
athletic trainers are referred to as sport physiotherapists in the United Kingdom, the
questionnaire was renamed The Physiotherapist and Sport Psychology Questionnaire
(PSPQ), and relevant questions were reworded to reflect this professional title.

The ATSPQ was mailed to 1000 ATCs, with 482 questionnaires returned and
used in the analysis. The PSPQ was mailed to 179 chartered physiotherapists, with 90
being returned and used in the analysis. Responses to the Likert scale questions were of
similar value and ordering across both ATCs and physiotherapists. For example, ATCs
and physiotherapists were asked how often short-term goals were used when working
with injured athletes (Likert scale: 1, never use; 2, use 25% of the time; 3, use 50% of the
time; 4, use 75% of the time; 5 use 100% of the time). Average scores for ATCs for this
question was 4.34, and for physiotherapists was 4.32 (Hemmings & Povey, 2002; Larson
et a1., 1996). Not only were answers to Likert scale questions similar across professions
and countries, but answers to the open-ended questions were similar as well.
Professionals in the two studies listed the same top-five characteristics of athletes who
cope successfully, and four of the top-five characteristics of athletes who cope
unsuccessfully, which included compliance with the rehabilitation program, positive
attitude, motivated to rehabilitate, patience with the injury program, and determination.
This similarity between the two studies indicated that injury—relevant psychological issues

are similar across athletes at multiple competitive levels and countries. Additionally, the

26

similarity of results in ATCs and sport physiotherapists in two countries and across
multiple settings strengthened the generalizability of results. These results also supported
the earlier findings of Weise, et. a1. (1991), with professionals in both studies expressing
a strong interest in Ieaming more about each of the skills presented in the ATSPQ or
PSPQ. These findings on the use of sport psychology in the athletic training room were
further substantiated by a 1997 survey of ATCs, physical therapists, and physicians. This
study confirmed the belief that while allied health professionals recognize the
psychological component to injury and are generally receptive to the use of psychological
strategies in rehabilitation, many feel they lacked the necessary skills and knowledge to
teach these strategies (Crossman, 1997).

Taken together, the results of these studies may be best used to advise athletic
training educators of the importance of including mental skills and strategies into their
programs. If ATCs are not educated about the benefits of sport psychology techniques
and strategies, they would be unwilling or unable to instruct athletes on the use of such
skills during injury rehabilitation. Research also indicated that if ATCs are provided with
education regarding the theory and implementation of psychological skills and
techniques, they would use it.

Psychological Skills Training (PST) Techniques

The course of rehabilitation is not always consistent, and psychological factors
involved with injury response may influence treatment compliance and rehabilitation
performance in many ways (Hell, 1993; J. Taylor & Taylor, 1997). Over half of injured
persons fail to comply with their rehabilitation program to some degree (A. H. Taylor &
May, 1996), and more than 200 variables have been associated with rehabilitation

compliance (Fisher, 1990; Fisher et al., 1993). A number of psychological interventions

27

have been recommended to increase adherence to rehabilitation protocols and to facilitate
the physical rehabilitation of injured athletes. In addition to counseling and peer
modeling, these interventions include cognitive restructuring, imagery, relaxation, and
goal setting (B. W. Brewer et a1., 1994). However, we learned that college athletes
generally underutilize mental health services (Bergandi & Wittig, 1984), so non-
mainstream techniques (e.g., imagery, relaxation) may be viewed with skepticism. An
athlete must be confident in a treatment for that treatment to be effective; therefore, only
psychological interventions that have been demonstrated effective and that are perceived
as credible and acceptable to injured athletes will be beneficial (Ievleva & Orlick, 1991;
Meichenbaum & Turk, 1987). To explore this, in-depth discussions of each
psychological skills technique are contained in this review.

Stress Inoculation Training. Stress Inoculation Training (SIT) is a cognitive-
behavioral intervention that advocates educating the athlete about what to expect during
the rehabilitation process. Athletes are then provided with psychological skills so that
they may monitor and cope with their cognitive and emotional distress. SIT is comprised
of three components: conceptualization, skills acquisition, and application. During
conceptualization, athletes are provided rationale for understanding their cognitive and
emotional responses to surgery. They are informed that they will likely experience
anxiety and pain during rehabilitation, and that cognitive and behavioral interventions
have been found effective in decreasing distress and discomfort. In the skills acquisition
phase, athletes are trained to self-monitor their own individual cognitive and emotional
indicators of distress and pain. Finally, psychological strategies commonly used in SIT

included deep breathing, progressive relaxation, imagery, and positive self-talk. During

28

application, athletes are instructed to rehearse these strategies several times each day, and
to use them in response to distress and pain (Ross & Berger, 1996).

The effects of SIT on post-surgical anxiety, pain, and physical recovery were
prospectively evaluated in a group of 60 men having undergone arthroscopic repair of a
single meniscal tear (Ross & Berger, 1996). This group of men had never had surgical
treatment or physical therapy for any other athletic injury, which eliminated previous
experience as a potential confounder. Subjects were randomly assigned to either physical
therapy-only (PT-only) or physical therapy plus SIT (PT +SIT) conditions. The same
physical therapist supervised all rehabilitations, and this individual was blinded to
subjects’ group assignment. While state anxiety and pain decreased naturally over time
in both groups, statistical analyses indicated a significant group main effect for both
variables (p<0.001), signifying more rapid decreases in the SIT+PT group. Average
number of days to recovery (criterion: 80% of uninvolved knee strength for two
consecutive measurement sessions) was also found to be significantly less for subjects in
the SIT+PT group (23 < 29, p<0.001). This study provided empirical support for the use
of cognitive-behavioral interventions to enhance psychological and physical
rehabilitation of injured athletes. It was also an important initial step in establishing a
research base for psychological interventions with this population. Unfortunately, this
study only included Caucasian, male, non-professional athletes so it may not be
generalizable to all injured athletes. It does, however, make a strong argument for the
inclusion of psychological strategies in physical rehabilitation.

There were several hypotheses suggested to explain the effect of SIT procedures
on decreasing time needed to return to function. Relaxation and guided imagery have

been shown to facilitate decreased anxiety and pain during physical rehabilitation (Cupal

29

& Brewer, 2001). This decrease in anxiety and pain may facilitate vasodilation, which in
turn increases blood flow and speeds the physical healing process (Surwit, Pilon, &
Fenton, 1978). Alternatively, the decreased pain and anxiety produced by the SIT
procedures may have facilitated increased compliance with rehabilitation, resulting in
decreased number of days to recovery. This effect has been demonstrated in hospital
patients (Wells, Howard, Nowlin, & Vargas, 1986); however, there was no indication that
SIT+PT group participants attended more physical therapy sessions than the PT-only
group, nor was there evidence that subjects were more active during their rehabilitation
sessions. The final hypothesis was based on the attributional model, which suggests that
therapeutic gains may be increased by the presence of internal attributions for success

(e .g., effort) and external attributions for failures (e.g., the healing process) (Brehm &
Smith, 1986). Subjects trained in SIT procedures may view themselves as active
participants with a significant degree of self-control over their rehabilitation and
recovery, which may have then motivated them to make positive gains during physical
rehabilitation.

While there was clearly strong evidence for the use of a SIT program with injured
athletes, SIT is an extremely time-consuming process that incorporates several techniques
commonly used in sports psychology. Athletic trainers likely do not logistically have the
time to implement such an involved program with their injured athletes. Also, athletes
may not need training in each of these techniques; rather, techniques should be matched
to the individuals’ needs. It is important to examine the efficacy of individual
components of SIT to evaluate their relative contribution to achieving significant positive
outcomes in athletic injury recovery. The following sections will address these

components individually.

30

Somatic (Physiological) Interventions: Relaxation in Rehabilitation. A
combination of physiological (somatic), psychological, and behavioral responses occur
when an individual is worried, stressed, or afraid (Loundagin & Fisher, 1993). Voluntary
skeletal muscles are arranged in pairs. When a muscle tightens because of perceived
stress, its antagonist counterpart sets up a counter tension to hold the body segment in
place. This “double pull” causes excessive tension build up but is generally unidentified
by most people. Unresolved, increasing tension caused by worry or anxiety interferes
with performance because it causes pain and prevents appropriately coordinating
movement. The more muscular tension in the body, the more difficult it is to execute
good form or proper coordination in any type of movement task (J. M. Williams &
Harris, 2006). Specifically, tension works against the effectiveness of rehabilitation
exercises by decreasing blood flow and range of motion in the injured area (H. N.
Brewer, VanRaalte, & Linder, 1991; Ievleva & Orlick, 1993). Learning to relax is
essential to regulating these responses. An athlete can learn to reach this state voluntarily
by practicing relaxation skills and strategies. Skill in voluntary relaxation can play a role
in decreasing stress and speeding injury recovery (Loundagin & Fisher, 1993).

Physical relaxation facilitates mental control processes, thereby enabling inner
control over the body (Botterill, Flint, & Ievleva, 1996). Practicing a relaxation routine
could release tension and enhance blood circulation. The greater the bloodflow, the
faster injured issues are repaired (Ievleva & Orlick, I993). Athletes could become
proficient at identifying and releasing unwanted tension at will. Muscle-to-mind
techniques, such as Jacobson’s Progressive Relaxation, train muscles to become more
sensitive to any level of tension and to release (J. M. Williams & Harris. 2006).

However, while studies have demonstrated the effect of relaxation training on reducing

31

injury rate and injury severity (Davis, 1991), studies on the use of relaxation training with
injured athletes during recovery is much more limited. Injured athletes commonly
experience a pain-spasm-pain cycle which, if not controlled, has the potential to cause
further damage (Starkey, 1999). Relaxation training, combined with imagery and
positive self-talk, was used in a controlled, prospective study where all subjects received
physical therapy (Ross & Berger, 1996). As compared to the control group, participants
who were exposed to these three techniques demonstrated less post—operative pain and
anxiety during rehabilitation and returned to normal physical functioning more quickly.
While the effect of relaxation training alone has not been demonstrated independently of
the other psychological skills, there is empirical evidence that relaxation combined with
imagery has positive effects on injured athletes during recovery (Hamberger & Lohr,
1980; Porter & Foster, 1990).

Cognitive-Based Interventions: Positive Self- Talk, Thought-Stopping, and
Reframing. Any time an athlete carries on dialogue with him or herself, be it out loud or
internally, he or she is engaged in self-talk. Examples of self-talk include giving oneself
instructions or reinforcement, restating convictions, and interpreting what one is feeling.
Self-talk is an asset when it is used to enhance self-worth and performance, but can be a
liability when it distracts from the task or when it is used for negative self-labeling
(Zinsser, Bunker, & Williams, 2006). Athletes cannot change the fact that they have
been injured, but they can control their thoughts about injury and recovery. Numerous
studies have demonstrated increases in negative mood states in athletes following injury
(B. W. Brewer & Petrie, 1995; Crossman, 1997; Hamilton, Hamilton, Meltzer, Marshall,
& Molnar, 1989; Leddy, Lambert, & Ogles, 1994; McDonald & Hardy, 1990; T. Petrie,

Brewer, & Buntrock, 1997; Quackenbush & Crossman, 1994; Roh, Newcomer, Pema, &

32

Etzel, 1998; Schoene, 1998; Smith, Scott, O'Fallon, & Young, 1990; Smith, Scott, &
Wiese, 1990; Smith et a1., 1993). A certain amount of grieving is a natural part of the
injury process, however, it is much more productive to focus on the positives. Positive
self-talk contributes to personal well-being and can be focused on any ability, including
healing. Positive dialogue with one’s body, especially during injury rehabilitation, has
been recommended by experts for enhancing healing (Jaffe, 1980; Porter & Foster,
1986). What athletes say to themselves following injury helps determine subsequent
behaviors during the rehabilitation process. For example, athletes may choose to focus
on the negative aspects of injury (e .g., possible loss of starting role) or on the positive
aspects (e.g., recovering from injury builds character). There are many uses of self-talk
in athletics (Zinsser et a1., 2006).

Self—talk encompasses thought stopping, cognitive restructuring, countering,
reframing, and affirmation statements. These skills require conscious effort to screen
negative statements and to focus on personal strengths or positive aspects of a situation.
They are extremely useful in helping an athlete overcome the loss of confidence that
commonly follows injury. Self-talk can be used to aid in releaming movement patterns
during rehabilitation, to change bad habits, to maintain attention and control effort in
rehabilitation, to create or change mood and affect, and to build self-efficacy in the
body’s healing power (Zinsser et a1., 2006). Cognitive restructuring essentially involves
changing negative thoughts and dialogue to positive. This can be achieved by
countering, a technique in which underlying beliefs are refuted with facts or reasoning, or
through reframing, a type of self-talk in which an individual talks oneself through the
positive aspects of the situation, consciously drawing reversing negative perceptions.

Another technique, thought stopping, involves saying “STOP” internally when he or she

33

recognizes negative thoughts, then substituting a positive statement in place of the
negative thought (Worrell, 1992). It may also be helpful for athletes to use affirmation
statements: meaningful statements that are posted on mirrors and in locker rooms in an
attempt to change a negative focus (e.g., fake it ‘til you make it).

In the general medical literature, chances of survival in terminal illness are better
with a positive outlook and a fighting spirit (Achterberg, Matthews-Simonton, &
Simonton, 1977; Benson, 1984; Borysenko, 1982; Simonton & Shook, 1984). Successful
patients want to be well and plan to be well. The factors of attitude and outlook are
considered to be critical in virtually all types of rehabilitation. Athletes must be made to
realize that recovery depends on their positive attitude (Arnheim, 1985). A retrospective
study of injured athletes concluded that athletes who used highly positive self-talk during
rehabilitation and recovery healed the fastest from injury (Ievleva & Orlick, 1991).
These findings have been replicated in other studies, although the majority of patients
have denied using self-talk with rehabilitation (Scherzer et a1., 2001). This suggests that
while the use of positive self—talk has been correlated with positive effects during injury
rehabilitation, injured athletes must be educated on the benefits and encouraged to use the
skills. Athletic trainers should be taught how to incorporate self-talk, thought stopping.
and reframing into injury rehabilitation programs. Athletic trainers should encourage
athletes to identify appropriate cue words to stop negative thoughts during challenging or
difficult situations, and to identify negative self-talk about the injury and reframe it.

Imagery in Rehabilitation. While many psychological techniques are in their
infancy with respect to the rehabilitation research and application, mental imagery is
arguably one of the youngest. Imagery, or visualization, is a technique which utilizes all

the senses to re—create or create an experience in the mind (Vealey & Greenleaf, 2006). It

34

has been theorized that when individuals engage in vivid imagery, the brain interprets
these images as identical to the actual stimulus situation (Marks, 1983). The power of
imagery allows athletes to practice physical and mental skills and strategies without
physically being in the training environment. Skills are thought to improve through the
psychoneuromuscular theory (Brett, 1987; Vealey, 1986), which suggests athletes’
imaginations can greatly influence their response to injury, however, many imagine the
worst that could happen. Athletes can be taught to control their visual images and to
direct them productively to decrease anxiety and aid in rehabilitation and successful
return to the performance arena (Vealey & Greenleaf, 2006). Similar impulses occur in
the brain and muscles when a movement is imagined without actually performing the
movement; vivid, imagined events produce innervation in our muscles similar to that
produced by the actual physical execution of the event (Richardson, 1967).

Although imagery has been shown to have motivational and cognitive functions
in training and competition and by patients in other types of rehabilitation (e.g., cancer
patients), it is still unclear whether it serves the same function in injury rehabilitation
(Sordoni, Hall, & Forwell, 2000, 2002). Once injury has occurred, imagery may be used
to increase relaxation, motivation, and self-confidence, and to decrease anxiety, manage
depression, and relieve pain (E. R. Korn, 1994). These effects have been demonstrated in
rehabilitation settings with cancer patients (Baider, Uziely, & De-Nour, I994; Syrjala,
Cummings, & Donaldson, 1992; Syrjala, Donaldson, Davis, Kippes, & Carr, 1995).
Injured athletes can also use imagery to rehearse desired rehabilitation outcomes such as
healing, returning to play, or executing specific skills (B. W. Brewer et a1., 1994).

Imagery is often separated into three distinct types: motivational, cognitive, and

healing. Motivational imagery can be used to help athletes control arousal and stress

35

levels, improve self-confidence, and set appropriate goals (e.g., imagining yourself being
self—confident when performing rehabilitation exercises, achieving treatment goals,
working successfully through tough situations). Athletes can use motivational imagery to
rehearse effectively overcoming anticipated problems or obstacles that may stand in the
way of successful return to the performance arena (J. M. Williams & Scherzer, 2006).
Cognitive imagery refers to imagining rehabilitation skills and strategies (e.g., imagining
yourself completing each rehabilitation exercise) (Sordoni et a1., 2000). For example,
athletes may visualize successfully completing a new exercise that requires the athlete to
re—learn muscle firing patterns and timing. Healing imagery involves imaging positive
physiological changes and has been reported to increase healing in cancer patients
(Sordoni et a1., 2002). Healing imagery operates on the basic principle of mind over
matter; the mind has the power to influence one’s immune response, resulting in faster
recovery. There is constant interchange between mental and physiological functions, so
the mind and body must work together. Imagery is one psychological intervention that
focuses on this principle, and there are strong arguments for its use in athletic injury
rehabilitation (Green, 1992; E. Korn, 1984; Sordoni et a1., 2002).

Research indicates that injured athletes use both motivational and cognitive
imagery less during rehabilitation than non-injured athletes during sport situations.
(Sordoni et a1., 2000, 2002). Studies are divided regarding factors that influence use of
imagery during injury rehabilitation (Milne, Hall, & Forwell, 2005; Sordoni et a1., 2000,
2002), but we can conclude that the athletes who have used imagery previously or who
have been rehabilitating longer realize the importance of transferring imagery used in
sport to their current situation. It may also indicate that athletes have found the use of

imagery during rehabilitation successful in the past (Sordoni et a1., 2002). In

36

retrospective studies, motivational imagery has been reported to increase injured athletes’
level of self—efficacy by increasing feelings of personal control, especially when dealing
with stress. Use of motivational imagery was also associated with a more rapid return to
activity and competition (Ievleva & Orlick, 1991 ). However, these results were based on
retrospective subject interviews, not on a prospective intervention. Injured athletes report
using cognitive imagery less than motivational injury during rehabilitation. This finding
is likely the result of unchallenging exercises or failure of athletes to recognize
rehabilitation exercises as skills (Sordoni et a1., 2000).

The frequency of use of healing imagery during rehabilitation is quite variable
across the literature (Scherzer et a1., 2001; Sordoni et a1., 2002). This variance is likely
the result of the amount of education provided by ATCs or health care providers about
the injury and encouragement in using healing imagery. The use of healing imagery
would likely increase across all injured athletes if health care professionals explained the
benefits of healing imagery, and. if needed, destigmatized its use. By educating athletes
about injury using anatomical models and by explaining the benefits of healing imagery,
a base has been provided from which athletes can apply healing imagery. Both
prospective and retrospective studies have demonstrated a positive relationship between
the use of healing imagery and recovery time (Durso-Cupal, 1996; Ievleva & Orlick,
1991; Potter & Grove, 1999; Ross & Berger, 1996). One study indicated that the use of
healing imagery was one of the top three variables positively related to faster recovery
from knee and ankle injuries (Ievleva & Orlick, 1991). However, this finding is only
consistent when athletes do not report extensive in jury—replay imagery (Green, 1992;
Ievleva & Orlick, 1991), as negative images have been found to interfere with the

production of positive images of healing and recovery (Green. 1992: Porter & Foster,

37

1986). Athletes utilizing healing imagery have also reported experiencing less reinjury
anxiety and perceiving greater control over their recovery (Durso-Cupal, 1996).

Imagery is an extremely valuable skill and has great potential for use during
injury rehabilitation. The benefits of motivational, cognitive, and especially healing
imagery have been demonstrated across several contexts including athletic injury
(Sordoni et a1., 2002). Findings across all three types of imagery (healing, motivational,
and cognitive) suggest that ATCs and other allied health care providers need not be
overly concerned about teaching imagery to injured athletes, but rather should encourage
athletes to transfer their skill in imagery from sports performance into the rehabilitation
arena. Additionally, ATCs can enhance the benefits of imagery by providing information
on the injury and the healing process so that healing imagery can begin.

Cognitive-Somatic Interventions: Relaxation and Imagery. Cognitive-somatic
interventions refer to the combination of physiological and mental techniques, most
commonly the combination of relaxation training and imagery. Relaxation facilitates
imagery by decreasing distracting stimuli, aiding in recall, and clarifying the visual
representation of experiences (Hamberger & Lohr, 1980; Porter & Foster, 1990).
Relaxation and imagery together are thought to decrease tension and anxiety, assist in
pain management, and promote healing. The two are among the most frequently
advocated psychological interventions for the rehabilitation of sports injuries. Preliminary
evidence indicates that the use of combined imagery and relaxation in athletes with long-
term injuries results in athletes having better moods (Green. 1992; Hell, 1993; J. Taylor
& Taylor, 1997).

One of the first published controlled studies to evaluate the efficacy of relaxation

and guided imagery during rehabilitation examined their effect on knee strength, re-injury

38

anxiety, and pain following anterior cruciate ligament reconstruction (Cupal & Brewer,
2001). Preliminary studies have shown that imagery and supportive, nondirective contact
applied in a placebo condition was perceived as equally as credible as guided imagery
interventions in sport injury rehabilitation (B. W. Brewer et a1., 1994). This study used a
placebo group in addition to a control group, with the placebo group receiving attention,
encouragement, and support. Treatment, placebo, and control groups each received
standard physical therapy by the same therapist who was blinded to group assignment.
The treatment group attended 10 bi-weekly PST sessions across the six-month
rehabilitation process. Sessions were conducted by the same clinician with 14 years of
experience in the techniques and consisted of three main elements: (a) addressing specific
physical processes at work during each stage of recovery (edema, pain, inflammation)
with videotapes of the arthroscopic surgery serving as a visual baseline; (b) using varied
imagery skills (e.g., visual, kinesthetic) to facilitate vivid mental experiencing and mental
rehearsal of specific physical rehabilitation goals appropriate for their state of recovery;
and (c) accommodating patients’ perceptions by including suggestions to promote
positive coping responses. Sessions were scripted and were identical for each treatment
group participant. Sessions were audiotaped and participants were instructed to listen to
the tape at least once per day until the next session. Placebo group participants received
attention, encouragement, and support in addition to standard physical therapy and were
asked to devote time each day to sitting quietly and visualizing a peaceful scene. During
physical therapy sessions clinicians reminded participants to practice this visualization.
Treatment and placebo groups were similar in that each was supervised by the same
trained clinician and that each had equal amounts of structured contact time with the

clinician, and time designated for out-of-clinic activities (listening to audiotape or

39

visualizing a peaceful scene). Results provided strong support for the use of relaxation
and guided imagery in sport injury rehabilitation programs. There was a significant
effect for treatment group membership for all variables (knee strength, reinjury anxiety,
pain). As compared to the control group, at 24 weeks knee strength was significantly
greater than both placebo and control groups. Also, while reinjury anxiety and pain
decreased across time for all groups, the treatment group experienced significantly faster
decreases in both (Cupal & Brewer, 2001).

There are several plausible theories to explain the physical recovery results of this
intervention. Possibly the intervention promoted the belief that the rate of recovery was
within the patient’s control. Post-experimental comments by treatment group participants
supported this assertion (Cupal & Brewer, 2001). If a treatment consisting of relaxation
and guided imagery produced significantly lower levels of anxiety and pain; perhaps
these reductions enabled patients to engage more fully in the rehabilitation program.
Participants in this group may have been relaxed enough to increase range of motion
more quickly. with increased motion facilitating strength training. This seems to be a
reasonable conclusion as knee strength was strongly correlated with both decreased
reinjury anxiety and pain over the course of rehabilitation in this study (Cupal & Brewer,
2001). There is also speculation that the intervention may have increased motivation,
thereby facilitating more positive outcomes (Cupal & Brewer, 2001). In addition,
psychological processes may have influenced the autonomic nervous system affecting
tissue regeneration-repair and immune-inflammation responses essential for healing
(Bresler, 1984; Penfield & Perot, 1963; Richey, I992; Rossi, 1994). We must keep in
mind, however, that these theories are only hypothesized. While possible, these theories

cannot be substantiated because this study did not measure the variables relevant to these

40

theories. While the exact mechanisms may not be known, there is adequate evidence to
suggest positive effects of incorporating relaxation and imagery into athletic injury
rehabilitation programs.

Behavioral Interventions: Goal Setting. In injury rehabilitation, goal setting is a
strategy in which the injured athlete and the ATC collaboratively establish rehabilitation
targets. In this process, an appropriate rehabilitation goal is identified, the importance of
the goal is assessed, and possible roadblocks to achieving the goal are identified.
Athletes and ATCs work together to construct a ladder of intermediate, short-term goals
to help achieve long-term outcomes (B. W. Brewer et a1., 1994). Experts have suggested
that goal setting can be used as a motivational and organizational tool to enhance
rehabilitation performance (Danish, 1986; S. Gordon, D. Milios, & R. Grove, 1991).
Literature on structured goal setting in athletic injury and rehabilitation indicates that goal
setting has a positive effect on athletes’ anxiety levels by providing a sense of control
over rehabilitation (Gould, 1986; Worrell, 1992) and by focusing thoughts on specific
actions and away from possible worries (Gould, 1986). Structured goal-setting programs
increase adherence and commitment to rehabilitation programs by providing athletes with
a sense of motivation (DePalma & DePalma, 1989; Penpraze & Mutrie, I999; Rotella &
Heyman, 1986; Scherzer et a1., 2001; J. Williams & Roepke, I993; Worrell, 1992). Goal
setting has also been theorized to increase performance by mobilizing effort, directing
attention to individual efforts and relevant aspects of the task, facilitating new learning
strategies, and prolonging persistence (Locke & Latham, 1990). In the athletic domain,
specific, challenging goals lead to increased performance versus easy, non-specific goals
or no goals (Theodorakis, 1995, 1996; Theodorakis, Malliou, Papaioannou, Beneca, &

Filactakidou, I996; Weinberg, Bruya, Longino, & Jackson, 1988).

41

Short-term goals must be distinguished from long—term goals. Daily short-term
goal setting was found to be more related to recovery time than long-term, return-to-sport
goals (Ievleva & Orlick, I991). Short-term goals and positive reinforcements facilitate
behavioral change and help take focus off of long-term goals that are unattainable in the
near future. Short-term goals require specific objectives. For goal setting to be effective
in the injury rehabilitation environment, the athlete must understand what functional
performance is required at each level of progression and must be able to connect the
relation of the daily functional goal attainment to a successful return to sport. However,
because athletes do not realistically have the skill required to develop short-terms goals
on their own, the ATC is in a position to help athletes set daily short—term goals that will
eventually lead to the achievement of the ultimate goal: return to play. The athlete is
rewarded or positively reinforced by the ATC each time he or she achieves a short-term
goal, and this helps the athlete develop a sense of control over injury (Worrell, 1992).

A study comparing introductory sessions on goal setting, relaxation and imagery,
and counseling (B. W. Brewer et a1., 1994) revealed injured athletes’ preference for goal
setting use that is consistent with previous research in this area (Fisher & Hoisington,
1993). One suggestion for this finding was that goal setting may be a natural part of an
uninjured athlete’s daily routine. If an athlete is comfortable setting goals for athletic
performance, this skill may be easily transferred to the context of sports injury
rehabilitation. Further, goal setting is more of a concrete exercise than the other sport
psychology techniques evaluated in this study (i.e., relaxation, imagery, counseling), so
athletes likely view themselves as playing an active role in the recovery process. Results

of the 1994 study also describe a significant positive correlation between rehabilitation

progress ratings and perceptions of goal setting (B. W. Brewer et a1., 1994). This may

42

suggest that athletes who perceive that their rehabilitation program is going favorably are
more likely to prefer goal setting, whereas those whose rehabilitation is not progressing
smoothly may become frustrated with goal setting if goals are not met on time.

Goals function in conjunction with other psychological variables such as self-
efficacy, or one’s expectation that he or she can successfully perform a specific behavior
required to produce a specific outcome (Bandura, 1977). Attainment of goals increases
self-efficacy, which in turn increases performance. To substantiate this theory, a series of
studies examining the effect of goal setting on quadriceps strength, pre-test anxiety, and
self-efficacy was undertaken. Subjects who had undergone arthroscopic knee surgery
and required quadriceps strengthening were recruited and randomly assigned to control or
treatment groups (Theodorakis, Beneca, Malliou, & Goudas, 1997). Participants in the
treatment group received feedback on performance of previous strength tests and set
goals for subsequent tests. Feedback was withheld from the control group because it has
been argued that when feedback is provided, individuals tend to set personal goals (Locke
& Latham, 1990). Treatment group participants in this study experienced significant
increased self-efficacy, decreased pre—test anxiety, and increased performance on the
quadriceps strength tests versus the control group. Treatment groups also outperformed
the control group in a previous study by the same authors (Theodorakis et a1., 1996). In
this study, four trials of a knee extension task on an isokinetic dynamometer were
performed by all study participants (T heodorakis et a1., 1996). The means of Trials 1 and
2 were considered the measure of the subject’s ability. Participants in the treatment
groups received feedback on their first two trials and set personal goals for Trial 3 , then
for Trial 4. Control group members were provided no feedback and only instructed to do

their best on each trial. Performance on the third and fourth trials was significantly

43

increased in both treatment groups, whereas performance actually decreased from trial to
trial under the control condition (T heodorakis et a1., 1996). This result can be explained
by the goal setting theory (Locke & Latham, 1990) which maintains that when
participants receive specific feedback, they are encouraged to set specific goals.
Feedback is a way of making explicit what it means to do one’s best. Unfortunately, a
limitation of both studies is a failure to include a placebo group in which feedback was
provided without encouragement in structured goal setting. This omission potentially
confounds the effects of a structured goal setting program because feedback was provided
to the treatment group only (Theodorakis et a1., 1997; Theodorakis et a1., 1996). Despite
this, it is conclusive that providing feedback on progress or performance and encouraging
structured goal setting results in increases in subsequent performance.

Educating the athletes in terms they can understand about the purpose behind the
exercise is likely to improve adherence and compliance. Furthermore, providing the
athlete with an understanding of what they can do to facilitate the healing process gives
the athlete a sense of control over their injury and recovery. Specific research on goal
setting has demonstrated the importance of ATCs and athletes collaboratively setting
goals, indicating that the ATCs are considered a source of social support only when they
are actively involved in the goal setting process with the athlete (Hartman, 1999). If
ATCs are educated about how to assist athletes in developing structured short-term goals,
the effectiveness of the entire rehabilitation process could be enhanced.

Applied Sport Psychology Course for Athletic Trainers

A review of the literature yielded only one study in which a course in applied

sport psychology for ATCs was implemented and evaluated (S. F. Pero, 1995). This

course was offered as either an optional workshop at the 1995 Eastern Athletic Trainers’

44

Association Clinical Symposium (27 participants) or as a self-study course (61
participants). Content included the role of the ATC within the psychology of injury
domain, pain perception, antecedents of injury, emotional response to injury, and applied
sport psychology in injury rehabilitation. However, specific topics included were not
identified, nor were the methods used to convey them. The author created a 28-item
sport psychology knowledge test, which was administered to participants one month prior
to the workshop (pre-pretest), at the beginning of the workshop to establish a baseline,
and again following the workshop as a post—test. A follow-up questionnaire was mailed
to participants one month after the workshop to determine how well ATCs could
implement the techniques Ieamed at the workshop. The response rate for all four test
periods was 65% for workshop attendees and 53% for home studiers. The author
reported a 43% increase from baseline knowledge in sport psychology knowledge; no
significant differences were found between workshop and home study groups.
Participants were asked at baseline how many sport psychology courses they had taken;
results indicated that the more sport psychology classes that a participant had taken, the
higher their sport psychology knowledge test scores. The majority of participants who
returned the follow-up questionnaire indicated that they were implementing sport
psychology techniques from the workshop. However, the author noted concern with the
inability to determine whether these techniques were actually being implemented, or if
they were being implemented correctly.

Suggestions for future research as presented by the author included conducting a
two- or three-part workshop and increasing the length of the workshop to allow for
“hands-on” practice of the techniques. The author also recommended evaluating longer-

temr retention of sport psychology and athletic training information, as well as

45

developing a method of assessing the ability of athletic trainers to utilize the
psychological skills training techniques during injury rehabilitation programs. A course
in psychology of injury for athletic trainers should also address the potential for dual-role
conflicts, as well as strategies that should be implemented by ATCs to prevent such
conflicts and other related ethical issues.
Summary

Athletes competing in all sports and at all levels are at risk for injury. Each year,
one in six athletes sustains an injury that will cause at least one missed day of athletic
participation (Ballard, 1996). Often overlooked in the injury treatment and rehabilitation
process are the psychological aspects of injury. The nature of the athletic training
profession puts ATCs in a position where they will be expected to handle many of these
injury-related psychological issues (Van Heerden & Potgieter, 2003), however, ATCs
have communicated the need for more formal training in psychological factors and
strategies associated with rehabilitation from athletic injury (Larson et a1., 1996; Moulton
et a1., 1997; Weise et a1., 1991). Areas that have been suggested as important components
of such training and education include communication and interpersonal skills.
counseling and social support, and psychological skills, such as relaxation, visualization
and imagery, goal setting, and self-talk.

Communication skills are essential for any professional in the allied health field.
These skills are especially important for ATCs throughout the injury and rehabilitation
process, from initial injury management, through the athletes’ emotional responses and
reactions to injury, to ensuring adherence and compliance to the rehabilitation program.
Athletic trainers should also receive some training in how to function as informal

counselors, as ATCs are often the first point of contact for athletes dealing with

46

emotional and psychological issues associated with injury. Although 90% of ATCs
reported counseling athletes in some area, 60% felt they had not been adequately
prepared to do so (S. P. Pero et a1., 2000). It is important to note, however, that even with
adequate education and training, ATCs must develop a referral network and be educated
on when and how to make a referral.

Aside from actual counseling and referral skills, ATCs should be trained to
provide appropriate levels of social support throughout the injury and rehabilitation
process, and to identify when athletes are not receiving adequate social support from
important others. Research has indicated that athletes look increasingly towards ATCs as
a source of social support during the rehabilitation process (Hartman, 1999; Robbins &
Rosenfeld, 2001), that rehabilitation adherence and compliance are positively related to
social support received from ATCs (Duda et a1., 1989; Fisher et a1., 1988), and that
athletes’ belief in rehabilitation effectiveness is influenced by the amount of social
support perceived to be available from ATCs (Bone & Fry, 2006). Athletic trainers can
also indirectly provide social support through goal setting (Ford & Gordon, 1993;
Hartman, 1999,2001) and through facilitation of injured athlete support groups and peer
modeling programs (Barefield & McCallister, 1997; Ford & Gordon, 1993; Singer &
Johnson, 1987; Udry, Gould, Bridges, & Tuffey, 1997).

Many studies have demonstrated positive effects of psychological skills on
performance enhancement, and recent studies have demonstrated positive effects with
injury rehabilitation as well. Psychological skills training techniques may facilitate
rehabilitation adherence (B. W. Brewer et a1., 1994; Heil, 1993; J. Taylor & Taylor,

1997). In particular, stress inoculation training, relaxation, imagery. self—talk, and goal

47

setting, used alone or in combination, have all been shown to have positive effects on
various portions of the athletic injury rehabilitation process.

This review concluded with a discussion of one attempt at a continuing education
course in sport psychology for ATCs (S. F. Pero, 1995). Although this corrrse had
somewhat equivocal success, the results are promising. A similar course designed for
athletic trainers may increase knowledge of relevant sport psychology techniques and
skills, and would have the potential to change the professional practice of ATCs.

Future Research Directions

Few studies to date have been conducted in which athletes were asked what
factors or characteristics of ATCs they perceive to be important during the injury and
rehabilitation processes. It is crucial for such research to be conducted with athletes, the
ultimate goal being to transfer this knowledge into teachable lessons for ATS. Recent
research has borne numerous articles focused on ATCs’ perceptions of sport psychology
in the athletic training room (Francis et a1., 2000; Larson et a1., 1996; Weise et a1., 1991).
These studies have explored the areas of communication, rehabilitation adherence,
motivation, and goal setting. While most studies identify strategies that the subject
population deemed successful in improving or implementing these techniques, few
suggestions are made regarding how these strategies can be taught to athletic trainers.
Additionally, more qualitative research is needed to explore the knowledge base and
comfort levels of recently-certified ATCs in these areas. These individuals will provide
the best information about what is, and is not, being included in ATEPs in terms of
communication skills, motivational strategies, social support and counseling, and use of
PST in athletic injury rehabilitation. From here, questionnaires should be constructed and

validated to quantitatively evaluate the use of essential skills and techniques that have

48

been qualitatively identified as being important by both athletes and ATCs. Quantitative
methodology is useful to explore perceptions of groups far too large to assess using
qualitative methodology. Quantitative methods also provide the means of determining
the relative importance of these skills and strategies.

This line of research should be extended to develop and evaluate an ATEP course
focused on training and educating of athletic trainers on psychological skills and
strategies that are useful and necessary for successful rehabilitation of the mind and body.
A sport psychology course for athletic trainers must be practical in nature, with emphasis
on both practical skills and theoretical concepts. It should address skills and techniques
such communication, motivation, social support and counseling, cognitive restructuring,
relaxation, imagery, and goal setting. In developing a course designed to teach these
skills to ATS, one must also consider the existence of a method to evaluate not only the
Ieaming of these skills during the course, but to evaluate the transferability of these skills.
It is important to understand the impact these skills have on ATS’ interaction with
athletes. To complicate matters, it is imperative to keep the mindset that these are young
and inexperienced athletic training students, not experienced and credentialed
professionals. Thus, the educational material must target the knowledge level and skill

base appropriate for entry-level athletic trainers.

49

CHAPTER 3

Identifying Psychosocial Competencies Needed By Certified Athletic Trainers
Background

When the idea for a course in applied sport psychology for athletic trainers was
first developed, it was realized that more information was needed about essential athletic
training psychological competencies than what was obtained through a review of the
literature. For this reason, a series of two qualitative studies was undertaken with the
purpose of identifying these essential psychological competencies. This purpose was
accomplished through individual interviews with currently or previously injured
collegiate student athletes (Study 1) and through focus group interviews with recently
certified ATCs (Study 2).

Study One: Athlete-Identified Strategies for Improving the Communication,

Motivation, and Social Support Skills of Athletic Trainers

The majority of the literature has used ATCs or sport physiotherapists to identify
the needs of injured athletes; very few studies have conducted research with injured
athletes themselves. In this study, currently or previously injured collegiate student-
athletes were asked a wide range of open-ended questions related to their positive and
negative experiences with ATCs. The purpose of this study was to identify important
aspects of the athlete-ATC relationship as reported by collegiate athletes, with the goal
being to identify essential psychological competencies that are needed by ATCs (Stiller

& Gould, 2006; Stiller, Gould, & Paule, 2006).

50

Method and Participants

A descriptive study using qualitative methodology was used to explore these
psychological issues. Qualitative research designs typically provide an in-depth analysis
of a small number of participants selected purposefully to achieve a stated goal and are an
excellent method of gaining initial knowledge in understudied areas by capturing the
richness and complexity of individual experiences (Patton, 1990). Due to the extensive
nature of the interviews the number of desired participants was set at 10, or until
saturation was reached. Semi-structured in-depth interviews were utilized to facilitate
comparisons across participants and to assist in the data analysis procedures. Key
research questions included: what ATC traits or behaviors characterize an ideal athlete-
to-athletic trainer relationship; how do athletes learn about injury; and how are athletes
motivated during rehabilitation (interview guide included as Appendix A). The length of
interviews ranged from 45 to 90 minutes, with all interviews being conducted by the
same individual who was both a certified athletic trainer and doctoral student in sport
psychology. Interviews were tape—recorded for later transcription and analysis. This
study was approved by the University Committee on Research Involving Human Subjects
(UCRIHS, Appendix B).

Nine student-athletes met predetermined criteria and were enrolled in the study.
A wide range of gender, race, class, injuries, and sport participation was represented
(Table 3.1). Individual interviews were recorded and transcribed verbatim. To determine
when saturation was reached, the investigator pre-coded the transcripts to identify
whether or not new information was emerging. Following the completion of all
interviews, a content analysis was used to analyze emerging themes in the raw data. Data

analysis required independent coding by two researchers. Peer debriefing was used to

51

ensure trustworthiness. Data were analyzed in a manner consistent with Patton’s (I990)
strategies for analysis.

Table 3.1. Athlete Participant Demographics

 

 

Participant Breakdown Sports Represented Injuries Sustained“;L
(# of athletes) (# of athletes)

M Age: 20.9 (1.16) Men’s Ice Hockey (2) Chronic Muscle Strain (3)
M years with sport: 13.4 (3.6) Football (2) Plantar Fasciitis (3)
Males: 6 Baseball (1) Medial Collateral Ligament
Females: 3 Softball (1) (MCL) Sprain (3)
Seniors: 3 Field Hockey (1) Anterior Cruciate Ligament
Juniors: 3 Women’s Basketball ( I) (ACL) Rupture (2)
Sophomores; 3 Men’s Lacrosse (1) Lateral Ankle Sprain (2)

Pelvis Fracture (1)
M injuries sustained: 3 Thumb Ulnar Collateral
M ATCs worked with: 3 Ligament Sprain (l)

Syndesmosis Rupture (l)
Posterior Labral Repair (1)
Recurrent Shoulder Sublux (1)
Chronic Low Back Pain (1)

 

tSome injuries were experienced more than once by the same athlete

Results

A total of 250 raw themes were extracted from the nine interview transcripts
related to the primary research questions. These themes were subsequently categorized
through content analysis into three general dimensions: communication and education (75

raw themes), motivation (42 raw themes), and social support (133 raw themes).

52

Complete results are presented in Table C1 (Appendix C), with the most important
findings highlighted below.

Communication and Athlete Education. Establishing rapport with athletes was
identified as a strategy for increasing rehabilitation compliance and ensuring prompt
reporting of injuries. Being provided with information and education about the injury
soon after it was sustained was identified by athletes in this study as being the first step in
the coping process. Additionally, clarifying expectations in terms of what athletes can
expect during rehabilitation and about what ATCs expect of athletes was identified as a
successful strategy for decreasing anxiety and frustration and increasing beliefs in the
effectiveness of the rehabilitation program. Good communication skills and effective
ATC communication strategies were perceived to be essential in preventing athletes from
being placed in too—advanced situations by coaches.

Motivation. Successful motivational strategies identified by athletes included
increased personal attention from ATC. perceived ability of athletes to play an active role
in rehabilitation, use of short—tenn goal setting, and ATC willingness to perform exercises
with the athlete. Personal attention from ATCs was mentioned by athletes in this study as
a factor that kept them motivated and working hard during rehabilitation. Similarly, the
willingness of an ATC to elicit and consider athlete feedback kept athletes motivated to
continue to work hard in rehabilitation. In terms of goal setting, motivation was
increased both by setting and meeting goals and by the excitement demonstrated by
ATCs when the goal was met. Athletes also mentioned some specific ways in which
ATCs kept them motivated and working hard throughout a long-term rehabilitation, such

as working out, running stairs and doing sprints with the injured athlete.

53

Social Support. A large group of raw themes emerged related to provision of
social support, indicating that injured athletes expect ATCs to provide many levels of
social support. The injured athletes in this study primarily expected support related to
their athletic injury, specifically, listening and emotional support, emotional challenge,
task appreciation, and task challenge. Additionally, they expected that ATCs should
possess the ability to listen, display empathy, and counsel athletes as needed in situations
unrelated to sport and injury.

Discussion and Implications

Athletic training education programs are now required to provide education
regarding psychological evaluation and care of injured athletes, however, these
competency guidelines are very general. Creating and maintaining an open, motivational,
and supportive environment in the athletic training room is an important step in ensuring
expedient return to sport, and the practical suggestions identified by athletes in this study
will be extremely useful to ATCs. Data obtained through this study are consistent with
the previous research on rehabilitation adherence strategies, provision of social support,
and successful ATC—athlete interactions (Bone & Fry, 2006; B. W. Brewer et a1., 1994;
Duda et a1., 1989; Fisher, 1990; Fisher & Hoisington, 19933; Fisher et a1., 1993) being
critical areas of interest. Data obtained through this study will be extrapolated into
standardized questions that will form the basis for follow-up studies. Information
gathered from this study will serve to enhance the education of future ATS, an area that is
virtually nonexistent in the current literature. The future application of research findings
to the athletic training educational system will benefit future athletes. The more we know
about how ATCs and athletes best interact, the more efficient. effective, and mutually

beneficial this relationship can be.

54

Study Two: Recently Certified Athletic Trainers" Perceptions of Essential
Psychological Components Within Athletic Training Education

Over the past 15 years a small body of research has been conducted with ATCs
and sport physiotherapists on the perceived importance of, and the need and desire for
knowledge in, psychological techniques and interpersonal skills that have been
recommended for use with injured athletes (Hemmings & Povey, 2002; Larson et a1.,
1996; Weise et a1., 1991). This research has targeted a wide age range of participants,
which would be desirable for most research purposes, but which provides no information
regarding what is currently being done in ATEPs in terms of psychological competencies.
The elimination of the internship route to certification in 2004 and the implementation of
standardized competencies has drastically changed the face of athletic training education.
and these new competency-based educational programs may better prepare and educate
athletic trainers in psychological competencies. For these reasons, the purpose of this
study was to assess the relevant psychological-based issues that newly certified athletic
trainers face and the extent to which their undergraduate education prepared them to
handle these issues. Weaknesses and limitations in undergraduate ATEPs regarding
preparation of students to handle various interpersonal and psychological issues they will
experience as ATCs were identified, with the goal of suggesting psychological
competencies to be included in ATEPs. Findings are discussed in relation to results
elicited from injured student-athletes in Study 1.
Method and Participants

A descriptive study using qualitative methodology was again utilized. Semi-
structured focus group interviews with ATCs were utilized to facilitate comparisons
across participants and to assist in the data analysis procedures. The length of interviews

55

ranged from 45 to 90 minutes, with all interviews being conducted by the same individual
who was both a certified athletic trainer and doctoral student in sport psychology.
Interviews were tape-recorded for later transcription and analysis. This study was
approved by the University Committee on Research Involving Human Subjects
(UCRIHS, Appendix D).

Eleven recently certified athletic trainers participated in three focus group
discussions (n,=5, n2=3, n3=3) of their educational preparation and professional
experiences related to enhancing athlete motivation, social support provision,
psychosocial referral, and psychological skills (e.g., imagery, relaxation, self-talk, goal
setting) used in injury rehabilitation. Key research questions included: athlete-related
issues; coach-related issues; motivation and compliance issues; psychosocial referral
experiences; and experience using PST with injured athletes (interview guide included as
Appendix E). Participants were asked to rank the level to which their undergraduate
ATEP prepared them to handle each set of issues (one to 10 scale; one being completely
unprepared, 10 being completely prepared). A wide range of undergraduate ATEPs,
sports worked, and current athletic training settings were represented (Table 3.2). Focus
group interviews were recorded and transcribed verbatim. To determine when saturation
was reached, the investigator pre-coded the transcripts to identify whether or not new
information was emerging. Once all focus group interviews were completed, a deductive
content analysis was used to analyze emerging themes in the raw data. Data analysis
required independent coding by two researchers. Peer debriefing was used to ensure
trustworthiness. Data were analyzed in a manner consistent with Patton’s (I990)

strategies for analysis.

56

Table 3.2. Athletic Trainer Participant Demographics

 

Participant Breakdown Undergraduate NCAA Current Athletic Training

Division Setting

 

M Years Certified: 2.7 (1.6) Accredited Division IA: 5 Full-time Assistant ATC: 3

(+/-1.6, range 0.5-6.0) Accredited Division IAA: l. Intern ATC: 2
Males: 3 Accredited Division II: 2 Graduate Assistant ATC
Females: 8 Accredited Division III: 4 (college setting): 4

Graduate Assistant ATC
(high school setting): 2

 

Results

Recently certified ATCs in this study indicated that they felt under-prepared to
handle many typical communication situations, including communicating effectively with
coaches regarding athletes’ injuries and playing status, developing relationships and
rapport with coaching staffs, and handling conflict with coaches. On a scale of one to 10,
the majority of ATCs ranked their communication preparedness between a four and a six.
In terms of dealing with injured athletes, ATCs expressed concern with the lack of
strategies they had for dealing with non-compliant and difficult athletes. ATCs also
expressed the need for more education and preparation regarding successful motivational
strategies in injury rehabilitation. While most ATCs could recall Ieaming goal setting (to
varying extents), others explained that they developed successful strategies through
experience and after many failed attempts. ATCs who had been taught goal setting and
used this technique with athletes found it to be very successful; however, ATCs

expressed the need for motivational strategies in addition to goal setting.

57

ATCs in this study reported being very under-prepared in terms of psychological
skills training (e.g., relaxation, centering, visualization/imagery), handling student-athlete
personal issues (e.g., pregnancy/abortion, eating disorders, death in a family, relationship
issues), and knowing when and how to refer for psychosocial issues. Individuals also felt
they lacked skills in mentally preparing athletes for return to sport following injury. As a
final question, ATCs were asked what suggestions for curriculum additions they would
make back to their undergraduate ATEPs. Suggestions included inserting more
psychological skills training education and practice, being involved in practical situations
in which counseling intervention or referral is necessary, and training in effective
communication.

Discussion and Implications

In general, injured student—athletes from Study 1 and recently certified athletic
trainers involved in these studies both agreed on the types of motivational strategies that
were effective. However, athletes indicated that ATCs should focus more on these
motivational strategies and the ATCs expressed the need for more educational training in
this area. It was the perspective of ATCs in this study that they were only expected to
provide athletes with injury-related social support, however, the athletes interviewed in
Study I desired all eight types of social support from their ATCs. The majority of
athletes in Study 1 indicated that they had no experience using PST in the athletic
training room, and the ATCs indicated that they had little, if any, educational preparation
in these techniques. Amongst ATCs there was a general consensus that PST would be
used in the athletic training room if ATCs had background knowledge about them, and
they expressed interest in learning more about these techniques. These findings are

consistent with previous research indicating that ATCs wanted more education in PST,

58

counseling, and referral issues, and that they would be willing to implement such
strategies if they felt properly educated (Larson et a1., 1996; Moulton et a1., 1997; S. P.
Pero et a1., 2000; Weise et a1., 1991).

Information gathered from this study will serve to enhance the education of future
ATS through a better understanding of the issues faced by recently certified athletic
trainers. This is an area that is virtually nonexistent in the current literature. The
application of research findings to the athletic training educational system will benefit
future ATS and ATCs. Knowledge and conclusions from this study have direct
application to ATEPs. The more we know about the issues new ATCs face, the more
effectively we can structure the athletic training education programs. Information
obtained through this study will be extrapolated into standardized questions that will form
the basis for the major dependent variables used in the third study in this series (Chapter

4).

59

CHAPTER 4

Developing and Assessing a Course Designed to Enhance Athletic Training Students’
Psychosocial Competencies
Method
Participants
After receiving approval from the University Committee on Research Involving

Human Subjects (UCRIHS, Appendix F), a convenience sample of students from a large
Midwestern University’s undergraduate and graduate ATEPs were invited to participate
in this study. Junior and senior level undergraduate and graduate students were recruited
for this study. The inclusion of graduate students was justified based on information
obtained from focus group interviews with 11 graduate student ATCs (Study 2, Chapter
3), which indicated that the majority of graduate students have had very little academic
preparation in applied sport psychology techniques during their undergraduate ATEPs.
An a priori power analysis based on an expected effect size of 0.7, a desired alpha level
of 0.05, and power equal to 0.80 indicated that 52 subjects would be the ideal sample
size. Initial contact with the pool of eligible participants was made during the first week
of the Fall 2007 Athletic Training Proficiencies course. The purpose and procedures of
the study were explained to the students, and they were asked to participate. It was
explained that participation in this research study would not prevent students from
participating in the proficiency course; rather, they would be given the opportunity to do
both during the study intervention period. Students were also advised that there were
neither benefits nor consequences for participating in this study, in that the knowledge

test and usage surveys would not be counted towards their course grade and the instructor

60

of the educational module was not responsible for any grading in the proficiency course.
Potential participants were informed that the workshop and seminar sessions would be
video recorded. Participants were assured that every attempt to exclude their images
from the recording would be taken, however, they were told that it was possible that they
may appear on the recording. A total of 31 out of a possible 32 participants provided
informed consent and were enrolled in the study. Although the power analysis indicated
that 52 subjects would be ideal for the study 32 was the total number available and
seemed large enough to assign a minimal size of 15 to each group.
Study Design

A simple intervention versus control group design was used in this study.
However, because ATS were assigned to their athletic team responsibilities prior to the
start of the study, a traditional simple randomization of participants to groups was not
possible due to the potential for cross-group contamination. Specifically, it was assumed
that participants assigned to the control group but working in the same athletic training
rooms on a daily basis with intervention group participants would be exposed to the skills
being taught in the intervention. Such contamination would effectively extinguish the
control group. For this reason a group allocation design was used; this type of allocation
is also referred to as composite randomization design or cluster randomization (Dohoo,
Martin, & Stryhn, 2003). In this case, individual athletic training rooms (n=7, Table 4.1)
were purposefully assigned to intervention or control groups based on the characteristics
of the ATS (i.e., academic class) and sports working out of each athletic training room.
This type of design is appropriate when the unit of comparison is not the individual, but
the group. Such is the case in this study, in which intervention and control groups are
being compared. Additionally, to ensure the integrity of the control group, participants in

61

the intervention group were stemly reminded at the beginning of each session to not
discuss information with participants in the control group.

Table 4.1. Athletic Training Room Characteristics

 

 

Sports by ATR ACIs Juniors Seniors Graduate Total Group
Assistants ATS
4 5 2 0 7 B

Football, Tennis, Field
Hockey

W Crew, M/W Soccer,

Dance, W Volleyball,

W Gymnastics, Cheer, 4 2 7 2 1 l A
Baseball, Softball, M/W

Track, X-Country

M Ice Hockey 1 1 0 0 I A
Wrestling, M/W Swim 2 0 2 1 3 B
W Basketball, M/W Golf 2 2 0 O 2 B
High Schools 1 and 2 2 0 I 2 3 A
High Schools 3-5 3 0 4 0 4 B

 

AC1: approved clinical instructor; ATR: athletic training room
M: men’s sport; W: women’s sport
Due to the relatively small number of participants in the intervention group (15

participants), the decision was made prior to the initiation of the study to replicate the
intervention with the control group (16 participants) after six weeks. At the end of Week
6, the participation of individuals assigned to the initial intervention group (Intervention
Group A) was complete. The control group then became Intervention Group B, with
their performance during the first six weeks of the semester serving as their own control.
Intervention B was implemented as planned, following the same procedures as was

intervention A. This study population number was considered acceptable because it

62

consisted of all participants in the target population at the University. Additionally, a
post-hoe power analysis indicated the study had power equal to 0.6015 given the output
effect sizes and the final sample size (31) for the primary intervention.
The Applied Sport Psychology for Athletic Trainers Educational Module

The Applied Sport Psychology for Athletic Trainers (ASP-AT) education module
was designed for upper-level (junior and senior) undergraduate students within an
approved ATEP. This intervention was designed to mirror how this course might be
implemented into undergraduate ATEPs. It is understood that the majority of ATEPs do
not have room within their curriculum for another full course. For this reason, this
module was designed to be easily incorporated into whatever course the undergraduate
ATEP is using to fulfill the Education Council’s competency on Psychosocial
Intervention and Referral, be it a proficiency course, a unit in an evaluation course, or
even into an already-existing sport psychology course. The module was designed to last
six weeks: two-hour workshops once a week for three weeks, followed by 30-minute
seminar sessions once a week for three weeks; thus, the entire course was completed in
seven and one-half hours over a six week period. Workshops and seminars were held
two nights each week. and students could choose which night to attend based on their
schedule. Workshop and seminar sessions were video recorded.

The specific content and schedule of course activities are included as Appendix
G. The ASP-AT was created based on a critical review of the literature (Chapter 2), data
from individual and focus group interview studies (Chapter 3), Psychosocial Intervention
and Referral competency guidelines (Council, 2006), personal experience, and
suggestions from experts within the field. All course materials were evaluated by a panel
of experts, including two ATCs with 12 years of combined experience, two sport

63

psychology consultants with nearly 55 years of combined experience, and one faculty
member with expertise in college teaching and pedagogy (33 years of experience).
Instrumentation

Questionnaire Development. In order to evaluate the effectiveness of this
educational intervention, a psychology of injury knowledge test (POI-K), a psychology of
injury usage survey (POI-U), and a psychology of injury transfer survey (POI-T) were
developed. The POI-K was designed to evaluate whether participants were learning the
content of the ASP-AT course. The purpose of the POI-U was to evaluate whether
participants were using the skills, techniques, and strategies Ieamed in the ASP-AT
course during their interactions with injured student-athletes. The ASP-AT was
developed to evaluate whether ATS were using these techniques effectively. This survey
was designed to be taken by injured student-athletes to evaluate ATS’ transfer of
classroom skills to real-world, athletic training room settings.

Survey construction was performed using the guidelines established by Raycov
(2007); a detailed description of survey construction is included as Appendix H. Survey
construction was essentially a five-step process. First, a critical review of the literature
(Chapter 2) and content analyses of open-ended interview questions with injured athletes
and recently certified athletic trainers (Chapter 3) were conducted to generate survey
items. Personal experience and direct observation of athlete-athletic trainer interactions
were used to generate additional items. Once an initial pool of items for each survey had
been compiled, input was solicited from experts in the field to help narrow and refine the
types of behavior pertaining to each construct (e .g., communication, attitude). Experts

included three ATCs with a combined 14 years of experience, one Association for

Applied Sport Psychology (AASP) certified sport psychology specialist with over 30
years of experience. and one ATC/sport psychology specialist with 8 years of experience.

An initial pool of items was then constructed: 62 for the POI-U, and 86 for the
POI-T (see Appendices I and J). The format of all items was a 9-choice Likert scale with
response scales ranging either from strongly disagree (1) to strongly agree (9), or from
never (1) to always (9). The initial survey instruments were reviewed for accuracy by
experts in the field, and were examined for wording and ambiguity by subjects in the
target population. The initial survey instruments were field tested with 215 ATS and 216
collegiate student-athletes. The pools of pilot test subjects were within the target
population (junior-level, senior-level, and graduate athletic training students and
collegiate student-athletes), but did not include participants who would be using the final
survey instrument. Comments were invited from pilot test participants on how they
perceived each item, and these suggestions were considered when developing the final
survey instruments. Exploratory factor analysis revealed one factor underlying each of
the six subscales on both the POI-U and POI-T, and all six scales demonstrated moderate
or high inter-item reliability coefficients (reliability coefficient range: 0627—091 1) and
cronbach’s coefficient alpha (internal consistence range: 0657-0910). Complete results
of factor analysis and reliability testing are presented in Appendix H. The final survey
instruments are included as Appendices K and L. The final POI-U consisted of 36 items,
with a range of possible scores from 36-324. The final POI—T consisted of 34 items, with
possible scores ranging from 34-306.

The POI—K was developed to assess improvement in students’ knowledge
following participation in the course. Three ATCs not associated with this study

participated in a mock ASP-AT course, then took the knowledge test. Modifications and

65

clarifications to the test were made based on suggestions solicited. The final POI-K
consisted of 28 open-ended questions, with a range of possible scores from zero to 73; the
POI-K and key are included as Appendices M and N.
Test- Taking Schedule

Once intervention or control groups were assigned, all participants completed pre-
course POI-K and POI—U tests. Scores on these two instruments served as a pre-
intervention baseline. Seven days following the third classroom session (Week 3),
participants in both the intervention and control groups were given the same POI-K and
POI-U that they had taken prior to the course. Students in the intervention group were
encouraged to study for this test in the same way that they would study for any test within
the athletic training major. Although participants in the control group were aware of the
test date, they were instructed to not prepare for the tests in any way. The rationale for
these instructions was to maintain the integrity of the control group. Athletic training
students who were not involved in this study would generally not study sport psychology
on a daily basis, and the purpose of the control group in this study was to simulate typical
athletic training students. It was the intention of this study to have injured student-
athletes complete the POI-T at the same periods as ATS completed the POI-U. However,
due to an unexpected decision on the part of the athletic training staff at this University,
access to injured athletes was denied (despite University human subjects approval and
athlete consent). For this reason, the POI-T was not administered to injured athletes and
the hypotheses related to POI-K (Hypotheses 5, 6, 7) were not tested.

Seven days following the third seminar session (Week 6), the POI-K and POI-U
were again administered to the intervention and control groups. Once again, intervention

group participants were encouraged to prepare as they would for any test in a course

66

within the athletic training major, while control group participants were instructed not to
prepare for the tests in any way. Participants in the intervention group reported studying
an average of 44.7 minutes (Group A) and 35.6 minutes (Group B) for the POI-K.
Following the completion of the tests, the intervention group was reminded that while
their participation in the weekly sessions was complete, they would be asked to take the
POI—K and POI-U again in seven weeks. They were told that they would not know on
what day the knowledge test would be administered, and were not encouraged to prepare
for this subsequent test. The purpose of this test was to assess knowledge retention.
Athletic training students would not generally study course materials after the course was
completed, therefore, participants were not encouraged to prepare for this retention test.
Control group participants were reminded that their participation in weekly classroom
sessions would begin the following week.

At Week 7 of the study period, control group members became Intervention
Group B and the intervention was replicated in the same manner as it was with
Intervention Group A. On the evening of the Week 14 of the study, the POI-K and P01-
U were administered to participants in intervention Group A (Retention Week 7). On the
evening of Week 20 of the study, the POI-K was administered to participants in both
intervention Group A and intervention Group B (Group B Retention Week 7, Group A
Retention Week 14). The design of this study is summarized in Figure 4.1. Inspection of
this figure shows when the intervention took place as well as the when the dependent
variables were assessed in each group. It also demonstrates how this module fits into a

typical academic semester.

67

Data Analysis Plan

Several sets of data analyses were run; one between-groups set to evaluate the
effectiveness of the Applied Sport Psychology for Athletic Trainers (ASP-AT)
educational intervention (Intervention Group A) as compared to the control group
(Hypotheses 1, 2), the second within—group set of analyses to evaluate the effectiveness
of the ASP-AT replication (Intervention Group B) to its own previous assessments when
it served as the control group for Intervention Group A (Hypotheses 3, 4, 8a-d). Finally,
the relative effectiveness of the intervention at Time A (Intervention Group A) and Time
B (Intervention Group B) was compared (Hypotheses 9a-9d), and retention over time was
evaluated (Research Question 1).

Primary Analyses. The first set of analyses was designed to evaluate the impact
of the intervention on participant psychology of injury knowledge (POI—K) and skills
usage (POI-U). A one-way Repeated Measures Analysis of Variance (RMA) was
conducted to evaluate group differences for each dependent variable (POI-K and POI-U
total score). The decision to use the total score of the POI-U, rather than the POI-U
subscales, was based on the small statistical sample size. Each RMA was a 2 x 3 (group
x time) analysis. A conservative f procedure was not needed because the correlations
between the two dependent variables were small (Table 4.2). The decision to run
repeated ANOVAs rather than one MANOVA was made based on the desire to evaluate
separate effects of the POI-K and POI-U. Consultation with a statistics expert (T.
Raycov, personal communication, March 13, 2007) confirmed the ability to substantively
defend the assumption of independence of participants. Although participants were

divided into seven athletic training rooms, each participant worked with a different

68

approved clinical instructor (AC1) or set of ACIs, thus preventing inter-dependence of
participants and upholding one of the primary ANOVA assumptions.

A one-way RMA was conducted to compare group scores on the POI-K at
baseline, Week 3, and Week 6 (means and standard deviations presented in Table 01).
The assumptions of homogeneity of covariance matrix and equality of error variances
were upheld; the Sphericity assumption was violated (Tables 02—04) necessitating the
use of the Huynh-Feldt correction in interpreting output. Results demonstrate a
significant group x time interaction (Wilks’ Lambda < 0.001 , partial eta squared = 0.720;
Huynh-Feldt < 0.001, partial eta squared = 0.651) (Tables 4.3 and 4.4), with an
inspection of the means indicating that the intervention was effective at increasing Group
A POI-K scores significantly more than Group B (control group) scores. The eta-squared
(0.651) indicates a significant effect of intervention, with 0.14 being the generally
accepted cut-off for a strong effect (J. Cohen, 1988). Because Group A contained more
Masters students than Group B, the RMA was re-run without Masters students. Group A
POI-K scores remained significantly higher than Group B even when controlling for
effects of the intervention on Masters students (Tables 05-07). Hypothesis 1:
Intervention Group A will demonstrate increased psychology of injury knowledge after a

6-week educational module versus a Control Group was therefore supported.

69

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Table 4.3. RMA Multivariate Output for POI-K

 

Effect

Value F

Hypothesis

df

Error
df

Sig

Partial Eta
Squared

 

Time Pillai’s Trace
Wilks’ Lambda
Hotelling’s Trace

Roy’s Largest Root

Time‘Group
Pillai’s Trace
Wilks’ Lambda
Hotelling’s Trace

Roy’s Largest Root

.789
.21 1

3.733
3.733

.720
.280

2.570
2.570

52.263
52.263
52.263
52.263

35 .987
35.987

2.000
2.000
2.000
2.000

2.000
2.000

35 .987
35 .987

2.000
2.000

Table 4.4. RMA Tests of Within-Subjects Effects for POI-K

28.000
28.000
28.000
28.000

28.000
28.000

28.000
28.000

.789
.789
.789
.789

.720
.720
.720

.720

 

Source

Type III Sum df

of Squares

hdean
Square

F

Sig

Partial Eta
Squared

 

Time
Sphericity Assumed
Greenhouse—Geisser
Huynh-Feldt
Lower-bound

Time‘Group
Sphericity Assumed
Greenhouse-Geisser
Huynh-Feldt
Lower-bound

5221 .807
5221 .807
5221 .807
5221 .807

3606.001
3606.001
3606.001
3606.001

1 .645
I .791
l .000

2

1 .645
l .791
I .000

2610.904
3175.121
2916.230
5221.807

1803.000
2192.630
2013.849
3606.001

76.399
76.399
76.399
76.399

54.140
54.140
54.140
54.140

.000
.000

.730
.730
.730
.730

.65 1
.65 l
.65 l
.65 I

To examine the pattern of change over time, a trend analysis was conducted.

Results demonstrated a linear trend for Group A, indicating that POI-K scores continued

to increase from baseline to Week 6 (Figure 4.2, Table 08). Pairwise comparisons

demonstrate significant group differences, and a significant time effect for Periods l and

2 (baseline to Week 3) and l and 3 (baseline to Week 6) indicating significant increases

in POI-K scores from baseline. There was a non-significant time effect for Periods 2 and

72

3 (p = 0.273; Tables 09 and 010). All results were significant when adjusting for

multiple comparisons using Bonferroni correction.

Figure 4.2. Group and Time Interactions for POI-K

 

 

 

 

 

 

g 80% -

v 60% ‘ 60%., ...— ——I 68% —l—Group A

g / —‘-—Group B

o , ,

g 40% r 25%/

>5 20% - I: ‘ H2296

5 20% 25%

“- 0% . . T .
Baseline Week 3 Week 6

A one-way RMA was conducted to compare total scores for the POI-U at
baseline, at Week 3, and at Week 6. A MANOVA with the six POI-U subscales could
not be conducted due to the group sample sizes; however, change in Group A scores are
detailed in Table 011. The means and standard deviations for POI-U total are presented
as Table 012. The assumptions of homogeneity of covariances matrix and equality of
error variances were upheld; the Sphericity assumption was violated (Tables 013-015),
resulting in the need to use the Huynh-Feldt correction in interpreting output. Results
demonstrate a significant group x time interaction (Wilks’ Lambda = 0.016, partial eta
squared = 0.256; Huynh-Feldt = 0.014, eqa squared = 0.149) (Tables 4.5, 4.6), with an
inspection of the means indicating that the intervention was effective at increasing Group
A POI—U scores significantly more than Group B scores. The eta-squared (0.149)
indicates a strong effect of intervention. These results were significant even when

controlling for the effects of the intervention on Masters students (Table 016-018).

73

Hypothesis 2: Intervention Group A will demonstrate increased usage of psychology of

injury techniques after a 6-week educational module versus a Control Group was

therefore supported.

Table 4.5. RMA Multivariate Output for POI—U

 

Effect

Value F

Hypothesis

df

Error
(If

Sig

Partial Eta

Squared

 

Time Pillai’s Trace
Wilks’ Lambda
Hotelling’s Trace
Roy’s Largest Root

Time‘Group
Pillai’s Trace
Wilks’ Lambda
Hotelling’s Trace
Roy’s Largest Root

.546
.454
l .202
l .202

.256
.744
.343
.343

16.831
16.831
16.831
16.831

4.805
4.805
4.805
4.805

2.000
2.000
2.000
2.000

2.000
2.000
2.000
2.000

28.000
28.000
28.000
28.000

28.000
28.000
28.000
28.000

.016
.016
.016
.016

.546
.546
.546
.546

.256
.256
.256
.256

 

Table 4.6. RMA Tests of Within-Subjects Effects for POI-U

 

Partial Eta
Squared

Source Type III Sum df

of Squares

Mean F Si g
Square

 

Time
Sphericity Assumed
Greenhouse-Geisser
Huynh-Feldt
Lower-bound

.428
.428
.428
.428

21 .676 000

21 .676 .000
21 .676 .000
21 .676 .000

14116.336 2

14116.336 1.546
14116.336 1.673
14116.336 1.000

7058.168
9128.823
8436.484
141 16.336

Time‘Group
Sphericity Assumed
Greenhouse-Geisser
Huynh-Feldt

Lower-bound

5 .072
5 .072
5 .072
5 .072

.009
.016
.014
.032

0.149
0.149
0.149
0.149

3303.218 2

3303.218 1.645
3303 .218 1.791
3303 .218 1.000

1651.609
2136.141
1974.134
3303.218

 

Results demonstrate a linear trend for Group A, indicating that psychology of

injury skill usage (measured by POI-U scores) increased in linear fashion from baseline

74

through Week 6 (Figure 4.3, Table 0.19). Pairwise comparisons for group demonstrate a
non-significant group difference (p = 0.175; Table 0.20), but a significant time effect for
all time periods (Periods l to 2, 2 to 3, I to 3; Table 0.21) indicating significant POI-U
score increases at each follow-up period. All results reported were adjusted for multiple

comparisons using Bonferroni correction.

Figure 4.3. Time Interaction for POI-U

 

 

 

 

 

 

 

245 a J
2 235 . I / I ~—l-—GroupA
o t—r—Group B
8 225 - f
5
195 I 1 I I
Baseline Week 3 Week 6

Although the primary intent was to demonstrate the impact of the intervention on
POI-K and POI—U scores separately, it was of interest to conduct a Multivariate Analysis
of Variance (MANOVA) to evaluate the overall effectiveness of the intervention. A one-
way MANOVA (2 dependent variables: POI-K, POI-U) was conducted. Results
demonstrate a significant main effect for group (Wilks’ Lambda <0.00l , partial eta
squared = 0.762; Table 4.7), indicating that the overall intervention was effective at
increasing both psychology of injury knowledge and skill usage. The partial eta-squared
value (0.762) demonstrates an extremely strong effect of the intervention. Univariate

tests were also significant, even when using the Bonferroni correction for multiple

75

comparisons (p < 0.025), confirming results of the separate RMAs for POI-K and POI-U

(Table 4.8).

Table 4.7. MANOVA Multivariate Output for POI-K and POI-U at Week 6

 

 

Effect Value F Hypothesis Error Sig Partial eta
df df Squared
Pillai’s Trace .762 44.785 2.000 28.000 .000 .762
Wilks’ Lambda .238 44.785 2.000 28.000 .000 .762
Hotelling’s Trace 3.199 44.785 2.000 28 .000 .000 .762
Roy’s Largest Root 3.199 44.785 2.000 28 .000 .000 .762

 

Note. Each F tests the multivariate effect of group. These tests are based on the linearly

independent pairwise comparisons among the estimated marginal means.

Table 4.8. MANOVA Univariate Output for POI-K and POI-U at Week 6

 

Dependent Variable Sum of (If Mean F Sig Partial Eta
Squares Squares Squared

 

Week6POI-U Contrast 6813.763 1 6813.763 6.128 .019 .174
Error 32245 .333 29 1 1 1 I 1.908

Week6 POI-K Contrast 8700.278 1 8700.278 87.346 .000 .751
Error 2888.593 29 99.607

 

Note. The F tests the effect of group. This test is based on the linearly independent

pairwise comparisons among the estimated marginal means.

Secondary Analyses. The second set of data analyses was run on the group that
first served as its own control and then served as Intervention Group B (Hypotheses 3, 4).
Separate analyses were run on this data set in order to determine the effect of group
assignment while controlling for individual-level variables, and to determine if
implementing the intervention later in the semester had a different effect on knowledge
gain or usage of skills (assuming, perhaps, that those students who took the class at the

beginning of the semester may have not had enough injured athletes with whom to use

76

the skills). To further evaluate the effectiveness of the replicated intervention
(Intervention Group B), both independent and dependent t—tests were conducted. A series
of dependent t-tests were conducted comparing Group B intervention Week 3 to their
control Week 3, and comparing Group B intervention Week 6 to their control Week 6
(Hypotheses 8a—8d). To evaluate relative effectiveness of the two intervention periods, a
series of independent t-tests were conducted comparing Group A intervention Week 3 to
Group B intervention Week 3, and comparing Group A intervention Week 6 to Group B
intervention Week 6 (Hypotheses 9a-9d).

A one-way RMA was conducted to evaluate single—group (Intervention Group B)
change over time for POI-K. The means and standard deviations are presented in Table
022. The Sphericity assumption was upheld (Table 023). Results demonstrate a
significant time effect (Wilks’ Lambda < 0.001, partial eta squared = 0.935; Table 4.9),
indicating a significant increase in POI-K from baseline to Week 6 of Group B
intervention. The effect size was extremely large (0.935), well beyond the 0.14 cut-off
for large effect. Hypothesis 3: Intervention Group B will demonstrate increased
psychology of injury knowledge after a 6-week educational module versus its own

control period was therefore supported.

Table 4.9. RMA Multivariate Output for POI-K (Group B Change Over Time)

 

 

Effect Value F Hypothesis Error Sig Partial Eta
df df Squared
Time
Pillai’s Trace .935 39.382 4.000 I 1.000 .000 .935
Wilks’ Lambda .065 39.382 4.000 H.000 .000 .935
Hotelling’s Trace 14.321 39.382 4.000 1 1.000 .000 .935
Roy’s Largest Root 14.321 39.382 4.000 I 1.000 .000 .935

 

77

To examine the pattern of change over time a trend analysis was conducted.
Results demonstrate a linear trend (Table 024). Pairwise comparisons demonstrate non-
significant time effects for Periods l to 2, and 2 to 3 (control period; p = l.000 and p =
0.798, respectively) but significant time effects for Periods 3 to 4 and 3 to 5 (intervention
period; p < 0.001) (Figure 4.4, Table 025), indicating that Group B POI-K scores did not
begin to increase significantly until participants began their intervention period (Times 4
and 5). All results reported were adjusted for multiple comparisons using Bonferroni

correction.

Figure 4.4. Trend Analysis for POI-K (Group B only)

 

 

 

 

 

 

g 60% -
V 50% - 4i 52%
2 40% 4 47%
o
a :2: ' .2 +
o - 229’ Grou B
1‘ 10% - 20% 25% o I p 1
2 0% r I I l 1
Baseline Control Week Control Week Intervention Intervention
3 6 Week 3 Week 6

A one-way RMA was conducted to evaluate single-group (Intervention Group B)
change over time for POI-U total. A MANOVA with Group B POI-U subscales could
not be conducted due to the sample size; however, change in Group B intervention scores
are detailed in Table 026. The means and standard deviations for POI-U total are
presented in Table 027. The sphericity assumption was violated (Table 028),
necessitating the Huynh-Feldt correction in interpreting output. Results demonstrate a

significant time effect (Wilks’ Lambda = 0.034, partial eta squared = 0.583; Huynh-Feldt
78

=0.001, partial eta squared = 0.343; Tables 4.10, 4.11), indicating a significant increase in
POI-U scores from baseline to intervention Week 6. Hypothesis 4: Intervention Group B
will demonstrate increased usage of psychology of injury techniques after a 6—week

educational module versus its own control period was therefore supported.

Table 4.10. RMA Multivariate Output for POI-U (Group B Only)

 

 

Effect Value F Hypothesis Error Sig Partial Eta
df df Squared
Time
Pillai’s Trace .583 3.840 4.000 1 1.000 .034 .583
Wilks’ Lambda .417 3.840 4.000 11.000 .034 .583
Hotelling’s Trace 1.396 3.840 4.000 1 1.000 .034 .583
Roy’s Largest Root 1.396 3.840 4.000 11.000 .034 .583

 

Table 4.11. RMA Tests of Within Sigiects Effects for POI-U (Group B Only)

 

 

Source Type III Sum df Mean F Sig Partial Eta
of Squares Square Squared
Time
Sphericity Assumed 8683.120 4 2170.780 7.324 .000 .343
Greenhouse-Geisser 8683 .120 2.036 4265.067 7.324 .003 .343
Huynh-Feldt 8683.120 2.385 3640.263 7.324 .001 .343
Lower-bound 8683 .120 l .000 8683.120 7 .324 .017 .343

 

To examine the pattern of change over time, a trend analysis was carried out and
found a linear trend for Group B (Figure 45; Table 029). Pairwise comparisons
demonstrate non-significant time effects for Periods 1, 2, and 3 (control periods). There
was a non-significant time effect between Periods 3 and 4 (p = 0.206), but a significant
effect between Periods 3 and 5 (p = 0.007; Table 030), indicating a non-significant
increase in POI-U scores at intervention Week 3, but a significant increase by
intervention Week 6. All results reported were adjusted for multiple comparisons using

Bonferroni correction.

79

Figure 4.5. Trend Analysis for POI-U (Group B only)

240 3
230 I
220 «
210 1
200

~ +Grou B
190 l D J

180 +

 

POI-U Score

 

 

Baseline Control Week Control Week Intervention Intervention
3 6 Week 3 Week6

Psychology of Injury Transfer Survey. Due to an unexpected decision on the part
of staff ATCs at this university who supervised all course participants, we were denied
access to injured student-athletes and were therefore unable to administer the POI-T. In
particular, access to the injured athletes was denied because staff ATCs felt that
participating in this study would be too time-consuming for their athletes. For this
reason, Hypotheses 5-7 could not be tested.

Exploratory Analyses. Dependent t-tests on Group B were conducted to evaluate
whether there was increased POI-K and POI-U scores during the intervention period, as
compared to control period (Hypotheses 8a-8d). Dependent t—tests were conducted on the
following paired samples: POI-K Control Week 3: Intervention Week 3 (15 (If); POI—K
Control Week 6: Intervention Week 6 (14 df); POI—U Control Week 3: Intervention Week
3 ( 15 (If); and POI-U Control Week 6: Intervention Week 6 ( l4 df); means and standard
deviations presented in Table 031. Results showed significant increases from control to
intervention for Week 3 and Week 6 POI-K, and for Week 6 POI-U even when using the

Bonferroni correction for multiple comparisons (used p < 0.0125; Table 4.12). This

80

indicates, even when controlling for individual-level differences, that the intervention
was effective at increasing POI-K scores at Week 3 continuing through Week 6, and at
increasing POI-U scores by Week 6. Hypotheses 8a, 8b, and 8d: Intervention Group B
will demonstrate increased psychology of injury knowledge at Intervention Week 3 and 6
and increased psychology of injury techniques usage at Intervention Week 6 as compared
to the control period were therefore supported. Hypothesis 8c: Intervention Group B will
demonstrate increased psychology of injury technique usage after Intervention Week 3 as

compared to the control was rejected (p = 0.919).

Table 4.12. Dependent t-tests for Group B Control: Intervention POI-K and POI-U

 

Mean SD SEM‘I' 95% CI of t df Sig. (2-
the Difference tailed)
Lower Upper

 

POI-K -l3.75 12.40430 3.10108 -20.35979 -7/l4021 -4.434 15 .000
Week3

POI-U 1.5 58.21569 1455392 —29.52095 32.52095 .103 15 .919
Week3
POI-K -21.8 8.43632 2.17825 -26.47188 -l7.12812 -10.008 14 .000
Week6
POI-U -15.86667 14.23209 3.67471 -23.74814 -7.98520 -4.318 14 .001
Week6

 

TSEM: standard error of mean

Independent t-tests were conducted with Group A and Group B at Week 3 and 6
of their respective intervention periods (A or B) to evaluate the relative effectiveness of
the two (Hypotheses 9a—9d). Independent t-tests were conducted on the following: POI-
K 3—week intervention (A:B), POI—K 6—week intervention (AzB), POI-U 3-week
intervention (AzB), POI-U 6-week intervention (AB) (28 (If). Results indicated no
difference in intervention period for POI-U at Week 3 or Week 6. but demonstrate

significantly different POI-K scores at both Week 3 and Week 6 (Table 4.13). An

81

inspection of the means demonstrates that POI-K was significantly increased in Group A
at both weeks (Table 032). This group difference is significant even when using the
Bonferroni correction for multiple comparisons (p < 0.0125: Table 4.13). Additionally.
because there were more Masters students in Group A than in Group B (three in A, one in
B), independent t—tests using undergraduate participants only were conducted. The group
difference for POI—K remained significant at Week 3, but was non-significant at Week 6
(Tables 4.14, Table 033). Hypotheses 9b, 9c, and 9d: Intervention Groups A and B will
demonstrate no differences in POI-K scores at Week 6 or differences in POI-U at Week 3
or Week 6 were therefore supported. Hypothesis 9a: Intervention Groups A and B will
demonstrate no differences in POI-K at Week 3 was rejected.

Finally, to evaluate retention over time (Research Question 1), the following
dependent t-tests were conducted: Groups A and B POI-K and POI-U at Intervention
Week 6 versus Retention Week 7 (evaluating percent decreased knowledge/skill usage at
Week 7 Retention); Groups A and B POI-K and POI-U Week 7 Retention versus baseline
(evaluating percent retained knowledge/skill usage increase from baseline); Group A
POI-K and POI-U Intervention Week 6 versus Retention Week 14 (evaluating percent
decreased knowledge/skill usage at Week 14 Retention); and Group A POI-K and POI-U
Retention Week 14 versus baseline (evaluating percent retained knowledge/skill usage
increase from baseline).

Group A and B paired sample statistics (means and standard deviations) for
baseline, Intervention Week 6, Retention Week 7, and Retention Week 14 are presented
in Tables 034-035. Dependent t-tests for Groups A and B combined are presented in
Table 4.15. Overall, Groups A and B demonstrated a significant 23.5% decrease in POI-

K at Retention Week 7 (p = 0.000) as compared to their POI—K scores at Week 6. but this

82

represented a 101.9% increase in POI-K score from baseline (p = 0.000) (Tables 4.15,
034). Retention Week 7 POI-U scores for Groups A and B combined demonstrated a
non-significant 2.1% decrease (p = 0.354) from Week 6 values, which represented a 21%
increase in usage from baseline (p = 0.000) (Tables 4.15, 035). When Groups A and B
were evaluated individually, Group A demonstrated the same magnitude of decreases for
POI-K and POI-U at Retention Week 7 (Tables 0.36, 0.37). Conversely, Group B
demonstrated a greater decrease in POI-K scores at Retention Week 7, but POI-U scores
actually increased (T ables O38, O39).

Intervention Group A was followed for 14 weeks post-intervention. At Retention
Week 14, Group A demonstrated a significant 35.2% decrease in POI-K (p = 0.000) as
compared to Week 6 POI-K, however this still represented a 76% increase in POI—K
scores from baseline (p = 0.000). Group A POI-U scores decreased by only 2.8% (p =
0.250) as compared to Week 6, which represented a 19.6% increase from baseline POI-U

scores (p = 0.000) (Tables O36, 037).

83

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86

Summary

In summary, the Applied Sport Psychology for Athletic Trainers (ASP-AT)
educational module was found to be effective at increasing psychology of injury
knowledge (as measured by POI-K) by Week 3, with continued improvement through
Week 6. The ASP-AT was effective at increasing psychology of injury skill usage (as
measured by POI-U) by Week 3, with continued significant increases through Week 6.
These findings were consistent across both intervention periods (A and B). Overall, there
was no difference in the impact of the module at Time A (Intervention Group A) or Time
B (Intervention Group B), indicating that the module can be implemented equally

effectively during either the first or second six weeks of the semester.

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CHAPTER 5

Discussion

Introduction

Due to frequent contact with injured athletes during injury recovery and
rehabilitation, ATCs are in a position to provide key psychosocial support. However,
while 70% of ATCs hold advanced degrees (Association, 2006), there is little
documentation that they receive graduate courses related to psychology and counseling
(Pennsylvania, 1998). The undergraduate setting is the ideal location for such a course,
as this placement would ensure that all ATCs who have met entry-level standards have
had formal education and have demonstrated competency in this content area. Athletic
training’s Education Council standards require formal instruction in Psychosocial
Intervention and Referral, but make no suggestions or requirements regarding how such
competencies must be taught. While this has the benefit of allowing ATEPs to
implement these competencies in any way that they choose, it may be a detriment to
athletic training students (as demonstrated in Study 2 of this dissertation). Competency
guidelines provided to ATEPs are very general, and there is a need for educational
preparation regarding specific, practical application of psychology of injury knowledge
relevant to athletic training.
Overview of ASP-AT Module Content

Effective ATC communication skills were identified by injured athletes in Study

1 as being extremely important for establishing rapport with injured athletes, which, in

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turn, ensures prompt reporting of injuries and compliance with rehabilitation. The
importance of communication skills on the part of ATCs continues throughout the entire
injury and rehabilitation processes, with athletes recalling how fully understanding the
ATC’s explanation of the injury was the first step in their coping process. Helping
athletes understand what to expect during rehabilitation functioned to decrease athlete
frustration and anxiety, and increase their belief in the success of the rehabilitation
program. These injured athletes felt that the most effective ATCs continued to clarify
athletes’ expectation through the return-to-sport phase, which both prevented athletes
from pushing their bodies too far and helped prevent too-high expectations on the part of
athletes. In Study 2, ATCs discussed the most effective communication skills and
strategies they have developed, but also discussed weaknesses of their educational
preparation in this area. The development of effective communication and athlete
education skills have repeatedly been recommended in the literature, particularly in terms
of improving athlete adherence to rehabilitation programs (Fisher & Hoisington, l993a;
Fisher et al., l993b; Fisher et a1., 1993), but research suggests more effective ATC-
athlete communication is needed. For this reason, a large portion of the ASP—AT module
course focused on teaching participants the importance of early, clear, informative
communication, as well as developing strategies to help improve their own
communication skills. Both in-class and out-of-class activities were implemented to
encourage participants to practice these skills with injured athletes, and sections of the
POI-K and POI—U were created to evaluate participants’ knowledge and skill usage

within this area.

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Athlete motivation was discussed at length by participants in both Study 1 and
Study 2, with both injured athletes and recently-certified ATCs detailing effective
motivational strategies. There was, however, a somewhat disturbing consensus amongst
athletes and ATCs regarding the use of motivation in the athletic training room, with
athletes discussing the lack of motivation they often receive from ATCs and ATCs
recalling learning little about motivational techniques (or how to improve athlete
adherence and compliance with rehabilitation) during their ATEPs. An understanding of
individual motivation has been cited as one of the top strategies of which ATCs should
have knowledge (Weise et a1., 1991); however, it was apparent from the two background
studies contained in this dissertation (Chapter 3) that many ATCs are not being educated
in this area and that athletes feel that motivation from ATCs is lacking. Previous research
with injured athletes confirms the under-utilization of motivation and adherence
strategies in the athletic training room (Fisher & Hoisington, l993a). For these reasons,
approximately one—third of the ASP-AT module course was dedicated to these two topics.
In terms of improving athlete adherence, participants Ieamed practical strategies for
gaining compliance, as well as strategies for dealing with ‘difficult’ or non-adherent
athletes. At the completion of the unit, participants worked through typical non-
compliance scenarios and had to use the information they had been given to strategize the
best method of ensuring athlete compliance. The difference between intrinsic and
extrinsic motivation as they relate to athletic injury and rehabilitation was outlined. In
terms of extrinsic motivation, the focus was on simplistic, practical strategies that have
been identified by athletes and other ATCs (e .g., ATC participation in rehabilitation),

then shifted to more formal motivation strategies such as goal-setting. Subtopics within

goal-setting included its effect on rehabilitation performance, how to set proper process,
performance, and outcome goals, how to set S.M.A.R.T short-term goals, common
mistakes with goal-setting, and how to deal with an athlete who has failed to achieve a
goal by the deadline. In-class and out-of—class activities encouraged participants to
develop creative motivational strategies and to practice setting each type of goal with
their injured athletes. Sections of the POI-K and POI—U evaluated participants’
knowledge and usage of these strategies and techniques.

Although social support was a topic of discussion in both Study 1 and Study 2,
neither athletes nor ATCs emphasized it much, and it receives little attention in the
Psychosocial Intervention and Referral content area of the competency matrix (Council,
2006). However, given the recent body of research demonstrating the powerful effects of
ATC—provided social support during injury rehabilitation (Bone & Fry, 2006; Hartman,
1999; Richman et al., 1989; Robbins & Rosenfeld, 2001), the decision was made to
include a small section in the ASP-AT module course. Participants were given an
overview of the effects of ATC-provided social support, including its effects on athletes’
self-efficacy, anxiety levels, compliance, belief in rehabilitation process, and impact on
perceived susceptibility of reinjury. Participants learned the generally accepted definition
of social support, as well as the appropriate ATC provision of all eight types of support,
and how they could facilitate support from these other important people in their athletes’
lives. Out-of-class activities encouraged participants to practice appropriate social
support provision, and sections of the POI-K and POI-U evaluated participant knowledge

and technique usage.

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In the final classroom session participants learned and practiced ‘sport
psychology’ techniques specific to their interactions with injured athletes. Topics
included muscle-to-mind techniques (with specific practice in Jacobson’s Progressive
Relaxation technique), problem— and emotion-focused coping techniques for dealing with
stress (with specific practice in centering), cognitive restructuring strategies (introduction
to self-talk with specific practice in techniques to control or reframe negative self-talk),
and imagery/visualization (with specific practice in developing healing imagery scripts).
This final session concluded with a review of referral situations and an overview of the
ATC’s role as an informal counselor. The purpose of this final unit was to help prepare
participants for situations they may encounter as ATCs. Previous research has shown that
90% of ATCs counsel athletes regarding injury—related problems, 77% counsel regarding
sport-related problems, and 65% counsel regarding personal problems (S. P. Pero et al.,
2000). However, it was the consensus of ATCs in Study 2 that the majority of
undergraduate ATEPs are not preparing students for this aspect of their professional
duties. These ATCs reported a serious lack of educational preparation and clinical
practice in this area and, as a result, reported feeling under-prepared to handle
psychosocial and referral situations they faced as ATCs. This finding was consistent with
other reports in the literature, in that the majority of ATCs surveyed felt unprepared or
underprepared to detect, counsel, and make referrals in many psychological areas (S.
Misasi et al., 1996; S. P. Misasi, 1998). To this extent, course material attempted to
differentiate between situations which do and do not require referral, helped participants

to develop strategies for approaching an athlete with a suspected issue, various “what to

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do when. . scenarios, and emphasized importance of documentation and how to
document confidential situations.

Through Study 1 and Study 2 (Chapter 3), the most effective communication and
athlete education strategies, adherence and motivation techniques, social support
provision, sport psychology techniques, and referral strategies thought to be important for
utilization by ATCs were identified. These studies expanded on previous research that
reported either athlete or ATC—identified strategies (Fisher & Hoisington, l993a; Fisher
et al., 1993; (Larson et al., 1996; Weise et al., 1991) by synthesizing results to create an
encompassing list based on the two perspectives. In addition to topics that emerged from
these two background studies, the Applied Sport Psychology for Athletic Trainers
module content was structured to include relevant findings from previous research into
these topics areas (Chapter 2), as well as the relevant Psychosocial Intervention and
Referral content area competencies and proficiencies focusing on antecedents to injury
(and the stress-in jury relationship in particular) and emotional responses to injury
(emphasizing the cognitive appraisal model) (Council, 2006).

While the intention was to make the ASP-AT module very practical, research was
incorporated into the course materials to demonstrate to participants that the information
was based on sound research studies, just as the information they receive in their
evaluation, modalities, and rehabilitation courses. Participants were also provided with a
“Toolbox” of in—class activities, and were required to complete seven out-of—class
assignments and to journal about the successes or challenges of implementing in-class
techniques with athletes in real-world settings. The module also consisted of 30-minute

seminar sessions once per week for three weeks, the purpose of which were to provide

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participants with the opportunity to check in with the instructor, to share their experiences
implementing techniques with athletes, to learn from others’ experiences, and to get
feedback regarding how to handle challenges that they were facing. Each seminar
session began with a review of course material and by asking participants what ways they
had found to implement techniques over the past week. These sessions simulated how
this module would be implemented in a true ATEP setting, in that athletic training
students would have the opportunity to ask follow-up questions to the instructor over the
course of the academic semester. Participants were required to attend at least two of the
three seminar sessions in order to remain in the study.

Given the content of the ASP-AT module and the limited class time
implementation would require (six hours), there are several options for placement of this
module within existing ATEP structures. One possibility would be to include it as one
unit within an already-existing sport psychology course. However, because the module
course content is so specific to athletic trainers, it may not be practical to include such a
large unit into a course which likely consists of a large percentage of non-athletic training
students. For this reason, it would be worthwhile to incorporate the module into an
ATEP core course. At the university used in this dissertation study, the module could be
easily incorporated into the Organization and Administration course, given the amount of
course material and the classroom time dedicated to it. Other practical suggestions would
include an advanced athletic training course, and athletic training procedures course, or a
special topics course. Preliminary analysis of data from an ongoing study designed to
evaluate the implementation of Psychosocial Intervention and Referral competencies

within ATEPs indicates that the majority of ATEPs whose program directors responded

are using the Administration and Organization, Therapeutic Rehabiltiation, or
Seminar/Special topics courses to teach Psychosocial Intervention and Referral
competencies. While there are clearly several course options in which to implement the
ASP-AT module, the question of who should teach the module is perhaps more
challenging. The ideal instructor is one who could be considered an ‘expert’ in either
athletic training or sport psychology, with a solid understanding of the role of sport
psychology within athletic training, or of ATCs’ use of sport psychology techniques.
Individual ATEPs should determine who among their faculty/staff best meets these
requirements.
Discussion of Statistical Effectiveness of the ASP—AT Module

The effectiveness of this educational module was excellent with nearly every
hypothesis being supported. Psychology of injury knowledge (as measured by the POI-
K) significantly improved by Week 3 of the intervention, with continued improvement
through Week 6. Although statistically significant knowledge increases were expected at
both Week 3 and Week 6 of the intervention, the lack of significant POI-K increase at
Week 6 may be explained by the dramatic knowledge increase by Week 3. The POI—K
consists of 28 questions for a total possible score of 73 points. By Week 3, individual
Group A participants scored as high as 635 points (87%; group average was 44.1 points,
60%). Additionally, POI-K scores did continue to increase from Week 3 to Week 6
(Group A Week 6 average score was 68%) while control group scores did not change
significantly from their baseline values. While an average score of 60% to 68% does
seem low, one must keep in mind the voluntary nature of this study. Although

participants reported studying an average of 40 minutes for each follow-up test (average

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of Groups A and B combined), knowledge test scores were was not tied into participants’
GPA, therefore there was less extrinsic incentive to increase quality or quantity of
studying. A second possible explanation for low average POI-K scores may be instructor
error. Both Intervention A and Intervention B were implemented exactly the same
(implemented as planned), however the instructor made notes throughout regarding what
should be changed for future ASP—AT course administration. With any new course, there
is an expected ‘learning curve’ as the instructor deciphers the best methods of
transferring information to students. An example of this phenomenon in this study is
Question I on the POI-K. Question 1 was answered correctly on only three of 168 POI-
K tests that were administered. This clearly indicated that (a) Question 1 was a bad
question, or (b) the instructor did not do a proper job preparing participants to answer this
question. Question I was also worth six of 73 possible points on the POI-K, so the
repeated incorrect answers on this question definitely effected average POI-K scores.
Nevertheless, the average baseline score (overall Group A and B average: 22%) indicates
two things: first, that participants did increase their psychology of injury knowledge
through participation in the ASP-AT module; and second, that there was an extreme need
for a module course in this area since athletic training students were grossly
underprepared within of the Psychosocial Intervention and Referral content area.

While retention testing at Week 7 and Week 14 indicated that participants lost a
significant portion of the knowledge they had initially gained, POI-K scores were still
significantly increased as compared to baseline values. This decrease in retained
knowledge is not completely unexpected. It has been reported that knowledge retention

generally falls to 75-89% of its original level after a relatively short period of time

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(Bruno, Ongaro. & Fraser, 2007). Additionally, previous research has suggested that 45-
60% of students become “unqualified” on course material three months following
completion of a course (based on students scoring below 70% on tested material) (Sisson.
Swartz, & Wolf, 1992). A meta-analysis of 96 studies evaluating student retention across
a wide range of subject matter found that one to four weeks following initial knowledge
gain, knowledge recall decreased an average of 19% and cognitive skill decreased an
average of 18%. In studies that evaluated knowledge retention between five and 13
weeks following initial knowledge gain, knowledge recall decreased by 18% and
cognitive skill decreased by 11% (Semb & Ellis, 1994). In studies related specifically to
psychology knowledge (the most similar topic contained in the meta-analysis), retention
follow-up intervals ranged from one to 80 weeks. In two studies that evaluated one-week
retention, recall knowledge decreased by 10.8% and 1 1.5% (Furukawa, 1977; Zimmer,
1985). Two studies with a six-week retention interval were split on cognitive skill
retention; one study reported skill decrease of 1.3% (Balcerzak, 1975) while the other
reported an increase of 3% (Halpin & Halpin, 1982). Finally, in one study with a 16-
week retention interval, knowledge recall and cognitive skill decreased by an average of
45.5% and 22%, respectively (Semb, Ellis, & Araujo, I993). Recall that in this
dissertation study, the groups demonstrated a 23 .5% decrease in POI-K scores at Week 7
retention, and a 35.2% decrease at Week 14 retention. Therefore, knowledge score
decreases in this dissertation study were within the ‘normal’ range that has been reported
previously in the psychology literature.

Shifting to psychology of injury skill usage, as expected there was a non-

significant increase POI-U scores until Week 6 with Group B participants. While

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immediate increases in knowledge were anticipated, it was predicted that it would take
longer for participants to find opportunities to transfer knowledge gained in the classroom
into implementing sills with injured athletes. Group A participants, however, had
significant increases in skill usage by Week 3, with continued significant increases
through Week 6. This immediate increase for Group A many be explained by further
interpretation of the trend analysis for Hypothesis 2 (Tables 0.20, 0.21). The trend
analysis for POI-U demonstrated no significant group difference for Group A and Control
Group, implying that some of the more ‘generic’ subscales may have increased in both
groups as a function of time spent with athletes. An examination of the data in Table

0.1 1 (i.e., attitude, relationship) shows this to be the likely explanation for the Week 3
increase in POI-U scores during Intervention A.

In contrast to the POI-K, retention testing for POI-U indicated that participants in
both Groups A and B continued using the skills with their athletes long after the module
was complete, with Week 7 and Week 14 POI-U retention tests demonstrated 98.8% and
97.2% retained usage, respectively. In fact, Group B participants actually increased POI-
U scores at Retention Week 7. There are several possible explanations for this increase,
the primary explanation being that Group B participant journal entries and comments
during seminar sessions indicated that they were actively using several techniques with
injured athletes. This increased usage during the intervention period likely transferred to
continued/increased technique usage at retention follow-ups.

The repeat ASP-AT intervention (Intervention Group B) was also found to be
effective at increasing both psychology of injury knowledge and skill usage

(demonstrated by both repeated measured ANOVA and dependent t-tests). The advantage

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of this change-over-time analysis is that using Group B as its own control eliminates the
possibility of any unmeasured group differences that may have been at play during the
control-intervention analysis (i.e., GPA, desire to succeed). It was also of interest to this
study to evaluate the relative effectiveness of the intervention at implementation Time A
(Intervention Group A; first six weeks of the semester) and implementation Time B
(Intervention Group B; second six weeks of the semester, ending two weeks before the
start of final exams). Every attempt was made to ensure that Intervention B was
“implemented as planned,” meaning that the dissemination of information, examples
utilized, and in-class activities were the same at intervention Time B as at intervention
Time A. To accomplish this, each two-hour classroom session for Group A was
videotaped, and these tapes were reviewed prior to implementing the same unit with
Group B. No significant differences were found for Week 3 or Week 6 POI-U, but
Intervention Group A had significantly increased POI-K scores at both time periods. One
explanation for this finding is that Group A contained three Masters students while Group
B contained only one Masters student. Although there were no significant group
differences in POI-K scores at baseline, Masters students may have scored higher on
follow-up testing than undergraduates, either because of higher academic class or because
they were better able to relate course material to athletic training situations. In fact, when
independent t-tests were conducted with Group A and B undergraduate participants only,
the significant group difference in POI-K scores at Week 6 disappeared (versus 0.01 ),
while Week 3 significance decreased (0.029 versus 0.009). One might also hypothesize
participants in intervention Group A may have had more time to focus on this extra

material earlier in the semester, versus later when assignments and exams increase. A

second explanation is that Group A contained stronger overall students (based on tacit
knowledge of primary researcher after having study participants in class during previous
semesters; participant GPAs were not recorded). A third explanation is that participants
in Group A studied longer than Group B (Group A average study time was 44.7 minutes,
as compared to the average of 35.6 minutes reported by Group B participants). Several
participants in Group A also told the researcher that they wanted to do well on the POI-K
so that the dissertation study was a success. This attitude may have spread to other
Group A participants and may partially account for increased Group A knowledge scores
(as compared to Group B intervention POI-K scores). For these reasons, it can only be
stated that it may be more effective to implement the module earlier in the semester.
However, due to potential unmeasured differences between Group A and Group B (e.g.,
GPA, desire to succeed), this statistical significance may not have practical significance.
Contribution to the Literature

A review of the literature produced only one other attempt at a course in sport
psychology for athletic trainers (Pero, 1995). This course was in the form of a workshop
at the Eastern Athletic Trainers’ Association regional conference. Paying participants
could choose to attend the course at the conference, or could take the workshop as a
home-study. Workshop content included antecedents to injury, emotional response to
injury, athlete pain perception, and applied sport psychology in injury rehabilitation.
Specific topics were not identified, nor were the methods used to convey them. The
author created a 28-item sport psychology knowledge test (psychometric properties not
provided), which was administered to participants one month prior to the workshop (pre-

pretest), at the beginning of the workshop (baseline), and following the workshop

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(immediate post-test). A follow-up questionnaire was mailed to participants one month
after the workshop to determine how well ATCs could implement the techniques learned.
The response rate for the four test periods was 65% for workshop attendees and 53% for
home studiers. The author reported a 43% increase from baseline sport psychology
knowledge; no significant differences were found between workshop and home study
groups. The majority of participants who returned the follow-up questionnaire indicated
that they were implementing sport psychology techniques from the workshop. However,
the author notes the inability to determine whether these techniques were actually being
implemented. Additionally, lack of 100% response rate on follow-up testing prevents full
trust that the course increased knowledge by an average of 43%, as there is no way to
know how much knowledge was gained by the 35—46% of participants who were lost to
follow-up. Another major concern of this study was the potential for selection bias. The
format of the workshop required ATCs to pay to participate; therefore, obviously only
ATCs who were sincerely interested and ‘bought into’ the material would have enrolled.
In the ASP-AT study, 97% (31/32) of eligible participants were enrolled, and all
participants who completed the six-week course returned for follow-up retention testing.
Conclusions

In conclusion, a 6-week educational module consisting of three two—hour
classroom sessions, followed by three 30-minute seminar sessions was found to be
effective at increasing psychology of injury knowledge and skill usage in undergraduate
and Masters degree candidate athletic training students. The ASP-AT module was
designed in this fashion so that this educational module could be easily incorporated into

existing ATEP structures. Participants spent only six hours in classroom sessions. the

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implication being that ATEP instructors would have to dedicate only six hours of class
time during a semester to a unit on psychology of injury to get similar knowledge and
skill usage increases in their students. The content that was included in the ASP-AT
module was a compilation of content suggestions from previous research (Bone & Fry,
2006; Fisher & Hoisington, l993a; Fisher et al., 1993b; Hartman, 1999, 2001; Hemmings
& Povey, 2002; Larson et al., 1996; S. P. Misasi et al., 1998a; Rosenfeld, Wilder, Crace,
& Hardy, 1990; Weise et al., 1991), content identified through needs assessments with
injured athletes and recently-certified ATCs (Studies 1 and 2; Chapter 3), and content
required to be taught in ATEP competencies and proficiencies as dictated by the
Education Council (Council, 2006). This content should be sufficient to prepare ATS
within the Psychosocial Intervention and Referral content area.

One major contribution of this study to the relevant literature is the longitudinal
nature of the follow-up testing. All participants who completed the module were
followed for seven weeks post-intervention, and Group A participants were followed for
14 weeks (over three months post—intervention). The purpose of this long retention was
to evaluate how well participants retained knowledge and to assess continued skill usage.
While participants only retained 64.8% of the knowledge they gained during the course,
skill usage with injured athletes only decreased by 2.8%. Additionally, while both
knowledge and skill usage decreased following the end of the retention period, these
decreased scores still represented an increase from baseline values. This type of follow-
up testing is not standard following a typical ATEP course, so there are no normative

values to which these retention values can be compared.

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The primary contribution of this dissertation to the literature is the all-
encompassing nature of the three studies contained in it. These three studies have
identified the psychosocial competencies that ATCs need to be taught during ATEPs, and
have demonstrated the effectiveness of the Applied Sport Psychology for Athletic
Trainers educational module at increasing knowledge in psychology of injury and athletic
trainers’ ability to transfer knowledge into skill usage with injured athletes the athletic
training room.

Participant Feedback and Pedagological Changes

Participants were asked to provide open-ended feedback at the end of the
intervention focused on what they gained from the ASP—AT module and suggestions for
improvements. Overall feedback was very positive, with the majority of participants
commenting on the usefulness of the strategies to handle difficult or non-compliant
athletes and on the practical motivation strategies that were discussed. Comments also
indicated that participants learned the importance of communication in the athletic
training room in terms of increasing prompt injury reporting, facilitating athletes’
emotional response to injury, and ensuring adherence to the rehabilitation program.
Several participants discussed their newfound appreciation of the role of social support
following injury and developed an understanding of athletes’ social support systems.
Perhaps the most commonly discussed benefit of the module was the sport psychology
techniques, including progressive relaxation, centering, imagery, and thought-stoppin g.
Participants appreciated the way material was presented in a manner that was “user-

friendly” for athletic trainers and could easily be incorporated with athletes in the athletic

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training room. The majority of in—class activities were rated as helpful and engaging,
with the S.M.A.R.T. goal-setting sheet being among the favorites.

Participants also had several suggestions for the improvement of the module.
While the majority felt that the ‘homework’ assignments were reasonable, athletic
training students found it difficult to implement many of the techniques due to limited
involvement with their athletes (i.e., not head athletic training student for their sport, no
long—term injuries). Overall, participants found in-class activities to be helpful, with
several suggestions focused on expanding the time spent on each to allow for students to
practice in class. Two participants suggested having a ‘lab’ session dedicated to this
practice where injured athletes might be brought in with whom students could work, and
another participant suggested incorporating “You-Tube” videos into the course that
would illustrate athletic trainers using the techniques with injured athletes in the athletic
training room. The primary complaint from participants was the timing of the class: a
two-hour evening session. Several participants commented that, while they were
interested in the material, the timing combined with the voluntary nature of the study
made it difficult to pay attention.
Limitations

As with any study, this study has its limitations. Although 31 of 32 eligible
participants were enrolled, 31 is statistically a small sample size. All participants were
recruited from the same ATEP and were therefore more similar to each other than
participants from other ATEPs would be. Additionally the inability to obtain feedback
from injured athletes (via the POI-T) somewhat decreased the strength of the usage

results. as no third party evaluation of ATS’ skill usage was possible. Finally, the course

104

was implemented by one instructor who was an expert in sport psychology’s application
to athletic training; therefore, the effectiveness of this module as taught by an ATEP
instructor not trained in these techniques cannot be substantiated.

Another limitation of this study was the failure to use a placebo control group: a
group who participated in a more generic six-week sport psychology course rather than
participating in the ASP—AT module. One explanation for the better POI—K scores in
Group A was the increased desire to succeed expressed by several participants. The use
of a placebo control group could have confirmed the impact of the ASP-AT module. If
participants in the ASP—AT module scored significantly better than both Control Group
and Placebo Control Group participants, this would have strengthened the results of this
study.

Future Research Directions

It was the original intention of this dissertation to evaluate the effectiveness of the
ASP-AT educational module in three ways: POI-K, POI-U, and POI-T (Psychology of
Injury Transfer; a usage survey completed by injured athletes regarding ATS’ skill usage
in the athletic training room). However, due an unexpected decision on the part of the
majority of the ATC staff who supervised all of the course participants, access to injured
athletes was denied. Future studies should make every effort to obtain feedback from this
athlete population, or from ACIs who supervise ATS, to provide more objective feedback
regarding the appropriateness of skill usage in practical settings.

It would also be of interest to evaluate the effect of this educational module in a
true classroom setting. Student participation in this study was voluntary with no external

motivation (i .e., course grade) for students to study for follow-up tests or to encourage

105

students to implement skills with injured athletes. One could certainly theorize that the
impact of this educational module would be even greater if students were graded on the
amount of knowledge gained and clinically evaluated on the appropriateness of skill
usage. Future research should also focus on ways to increase retention levels of
participants, perhaps utilizing student-friendly technology such as text message boosters,
or developing a self-monitoring or supervisor monitoring clinical evaluation/feedback
system. Additionally, while we recorded the amount of time participants reported
studying for follow-up knowledge tests, future studies should consider retrospective
interviews with participants who scored extremely high and extremely low on the POI-K
to evaluate particularly effective or ineffective study methods for Ieaming and retaining
psychology of injury content.

One of the limitations of this dissertation study was the fact that participants were
recruited from only one ATEP. These students would likely be more similar to each
other than to students from other ATEPs. Along the same lines, it would be interesting to
examine the impact of individual student differences on the effectiveness of the ASP-AT
module. For example, do some students (e.g., students with high emotional intelligence)
respond better to this module than others? Additionally, given the fact that some ATEP
instructors may not be comfortable teaching this content due to lack of familiarity with
the content, future research could be dedicated to assessing the effectiveness of the course
across instructors (inter-instructor reliability) and into developing continuing education
courses designed to improve ATEP instructors’ proficiency in teaching this content.
Future studies should focus on how to package the module best, and on the most effective

methods of ‘teaching the teacher’ (pedagological advice on instruction methods).

106

Research could also look into developing an internet course module and evaluating the
relative effectiveness of the classroom versus internet versions.

Finally, it would be of interest to conduct a longitudinal study within one ATEP
(or small subset of ATEPs) on ATS’ success rate on the Psychosocial Intervention and
Referral component of the National Certification examination. Success rate could be
retrospectively recorded for ATS who took the Certification examination prior to the
ATEP’s implementation of this educational module and prospectively recorded following
implementation of the module to evaluate how participation effects ATS’ success rate on
the examination. Such a study would be the ultimate evaluation of the practical

effectiveness of the ASP-AT educational module.

1 07

Appendix A

108

Appendix A

Interview Guide for Study 1

Opening Questions
1. Have you ever been injured during college?
a. Has an injury caused you to miss 1 or more days of practice or
competition during the last calendar year?
2. How many injuries have you had during college?
a. What types of injuries were they?
3. Have you had experience with several athletic trainers since you have been in
coHege?
Open-Ended Questions
1. Please discuss any POSITIVE experiences that you have had with your athletic
trainer (please be as specific as possible)
2. What traits or behaviors of an athletic trainer would cause you to believe that they are
competent at their job? (please be as specific as possible)
3. What traits or behaviors to you believe are characteristic of an ideal athlete-athletic
trainer relationship?
4. Please discuss any NEGATIVE experiences that you have had with your athletic
trainer (please be as specific as possible)
5. What traits or behaviors of an athletic trainer would cause you to believe that they are

NOT competent at their job? (please be as specific as possible)

109

If you have been in a situation where you and your athletic trainer did not get along,
what, if anything, did the athletic trainer do to try to repair the relationship?

Please discuss any positive or negative experiences you have had with your athletic
trainer in handling injury situations with your coach (sport coach or strength coach).
How does your athletic trainer motivate you in rehabilitation? (please list specific
examples or techniques if possible)

a. Ideally, what type of a role would you like to play in your own rehabilitation
process (how much say do you think you should have in what exercises you
do)?

What are some of the most effective techniques that your athletic trainer has used to
explain an injury to you?

a. Ideally, what would you like your athletic trainer to explain or education you

on?

110

Appendix B

111

Appendix B

Human Subjects Approval for Study 1

A Preliminary Investigation of Certified Athletic Trainers' Attitudes,
Actions, and Abilities As Viewed by Previously Injured Collegiate
Student-Athletes
Informed Consent Form

You are being asked to participate in a study conducted by Daniel Gould, PhD and
Jennifer Stiller, MS, ATC from Michigan State University, and John Ostrowski, MS,
ATC from the College of the Holy Cross. The purpose of this study is to better
understand the relationship between collegiate student-athletes and their athletic trainers.
This will be accomplished through addressing the research questions of: ( 1) what types of
positive and negative experiences have you had with your athletic trainer; (2) have you
ever had experience with an athletic trainer that you felt was effective but that you did not
like as a person; (3) has your athletic trainer ever confronted you to get you to work
harder in rehabilitation; (4) how has your athletic trainer facilitated or impaired
communication between you and your coach(es); (5) how does your athletic trainer
motivate you in rehabilitation; (6) how does your athletic trainer explain injuries to you;
and (7) how well or poorly does your athletic trainer fit in with your team.

As part of the study, you will be asked to participate in a 60-minute interview. The
interview will be audio taped and transcribed. If you so wish, you can refuse to have the
interview audio taped, or to have the audiotape turned off at any point during the
interview. Audiotapes will be erased at the completion of the study. In addition, you
may be contacted after the interview to clarify your responses to questions.

Your responses in the interview will remain confidential; no one except the primary
investigators and their research team will have access to these responses. Results will be
based on the answers given by all participants as a group, ensuring confidentiality of
individual responses. Group-based findings will be made available to those who are
interested. Your privacy will be protected to the maximum extent allowable by law.

Investigators will take measures to ensure the confidentiality of the participants by
eliminating names from interview transcriptions, data analyses documentation, and the
final project write up. Also, participation will be voluntary and you may withdraw from
participation at any time without penalty. Furthermore, you may refuse to answer
specific questions in the interview that you feel uncomfortable answering and can still be
a part of the study.

Your participation in this study would be greatly appreciated. If you have any questions
concerning your participation in this study, please contact the principle investigator Dr.
Daniel Gould at (517) 432-0175 or drgould@msu.edu, or Jennifer Stiller at (517) 353-

112

0728 or stillerj@msu.edu, or John Ostrowski at (508) 793-2627 or jowstows@holycross.
The investigators may also be reached by mail at: 205 IM Sports Circle, Michigan State

University, East Lansing, MI 48824.

If you have any questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may contact — anonymously, if
you wish — Peter Vasilenko, PhD., Chair of the University Committee on Research
Involving Human Subjects (UCRIHS) by phone: (517) 355-2180, fax (517) 432-4503, e-
mail: vasilenk@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI 48824.

Thank you for your time and cooperation,

 

 

Daniel Gould, PhD, Jennifer Stiller, MS, ATC,
Principle Investigator Secondary Investigator

 

John Ostrowski, MS, ATC, Investigator

Your signature below indicates your voluntary agreement to participate in this
study.

 

Participant Signature Date

Your signature below indicates your voluntary agreement to the audio taping of the
interview.

 

Participant Signature Date

This consent was approved by the Biomedical and Health Institutional Review Board
(BIRB) at Michigan State University. Approved 01—23-07 — valid through 01-22-08.
This version supersedes all previous versions. lRB#06-068

113

Appendix C

114

Appendix C

Athletes’ Communication, Social Support, and Motivation Expectations

Table C.1. Athletes’ Communication, Social Support, and Motivation Expectations

 

Raw Data Theme

First Order Second Order

 

Want to know what you’re doing &
why you’re doing it

“Huge” to understand how injury
occurred

Don’t know if it’s helping you or not

If I don’t understand why I can’t do
it, I’m going to do it

Explain why you’re doing an
exercise if it’s not obvious

Explain in terms an athlete can
understand

Need AT to explain it so you’re not
scared

Explain how working hard in rehab
will decrease my chance of re-injury
I want to know the extent of injury

Explain the purpose of the modality
I’m doing

Tell what the exercise will help you
do (ex: quicker on your feet)

Explain that it’s not always a straight
road to recovery

Pain is less scary when you know
why & that it’s normal

Tell athlete what kind of pain to
expect after surgery

Expectations post—op abilities (what
they can/can’t do)

I want to know everything on the
front end

AT should provide general idea, then
let athlete ask questions

Provide Adequate

Want Information Education (16)

Significance

Understandable Terms

Calm Re-injury Fears

Educate about Injury,
Treatments, Rehabilitation

Expectations of ATC &
Athlete

Explain Expectations
( 17)

Timeframe for Providing
Information

115

AT makes an effort to get to know
everyone

AT made a point to know each
teammate and their jersey numbers

AT came up and introduced himself,
so it was nice not to have to worry
Very awkward during rehab if you
don’t know the AT

AT makes sure coach knows my
status, how hard I’m working

AT takes “blame” for pulling an
athlete from practice

AT has authority to tell coach I need
a day off

AT can get my lifting program
altered

Have something closer to big goal to
help drive you towards it

AT took something I was looking
forward to and used that as a goal
Changing up exercises to make them
challenging

AT made a big deal when goals met

If goals aren’t meaningful, they
don’t motivate

Need to understand how goals will
get you back to play to be motivating
Mentally easier if you know you’re
making progress

AT helped create realistic goals
Having a goal with a time frame was
motivating

Set goals for where athlete wanted to
be when rehab worksheet was filled
AT asks me if there’s anything else I
feel I should be working on

AT listened to how body was
reacting to certain types of exercises
before deciding to increase or
change them

Knowledge about athletes
( 10)

Initial communication

with athletes

Communication

Authority

Challenging Goals,
Modifiable Goals

How STGs are
Motivating

S.M.A.R.T Goals

Ability to accept & use
athlete feedback

116

Establish Rapport
( l 6)

Communication with
Coaches (19)

Active Role in
Rehabilitation (31)

AT asked for my feedback during
early rehab so I wasn’t in more pain
than I could handle

If an exercise really hurts, AT comes
up with another that accomplishes
same purpose

Changing up exercises — always
doing new stuff

AT ran stairs & did sprints with me
AT wrote a card or pulled me aside
& said I was doing well & looking
good

When AT watches, you do it better
When AT notices I’m working hard
& getting things done it keeps me
motivated & on-task

Sometimes you just need to vent
Need to listen without giving advice
Need to listen without judging
Athlete needs to express what he
thinks is wrong physically

Someone to talk to without having to
wony about pressure

Need to talk about stuff that’s not
sport-related

AT isn’t into team politics

AT needs to be caring and bring over
the box of tissues

AT can understand the emotional
part of injury

Show concern for mental and
physical well-being

Redirect sadness into determination
to get better

Need someone to say “stop crying”
Remind you it’s not as bad as you
think

Put situation back into perspective
Remind you how far you’ve come

Creativity in Rehab

Supervision, Participation

ATC as a Sounding Board
(19) [Listening Support]

Supportive ( 16)
[Emotional Support]

Provided a Mental Push

(9)
[Emotional Challenge]

Provide Perspective (6)
[Reality Confirmation]

ll7

Creativity in Rehab
(6)

Personal Attention

(5)

Social Support (91)

Give crutches Physical Aid (8)

Helped set up modalities [Personal & Tangible
Drives athlete to the doctor/MRIIER Assistance]
Write me a card, a little pick-me-up Appreciative,

Understanding (13)
Show that they appreciate that I’m [Task Appreciation]

not always complaining

AT made a big deal of me achieving
my goal

Friends & family don’t appreciate
how hard it is and how hard I’m
working the way my AT does

Sometimes you need a kick in the Provided Physical

butt in rehabilitation Challenge (20)
[Task Challenge]

Pushed me, made sure I was on top

of everything

Made sure my rehab was as tough as

possible

Made sure I wasn’t slacking off, not

even taking a couple off

** Numbers in parentheses represents the number of raw data points

118

Appendix D

Human Subjects Approval for Study 2

A Preliminary Investigation of Issues Faced by Recently Certified
Athletic Trainers
Informed Consent Form

You are being asked to participate in a research study conducted by Jennifer Stiller, MS,
ATC and Daniel Gould, PhD from Michigan State University, and John Ostrowski, MS,
ATC from the College of the Holy Cross. The purpose of this study is assess relevant
rehabilitation, motivation, and communication issues that newly certified athletic trainers
face, and the extent to which his/her undergraduate education prepared him/her to handle
these issues. This will be accomplished through addressing issues pertaining to: (1)
athletes; (2) coaches and strength coaches; (3) supervisors; (4) athletic training students
and interns; (5) doctors; and (6) parents of student-athletes.

As part of the research study, you will be asked to participate in a 90-minute focus group
interview. The interview will be audio taped and transcribed. Audiotapes will be erased
at the completion of the study. In addition, you may be contacted after the interview to
clarify your responses to questions.

Your responses in the interview will remain confidential; no one except the primary
investigators and their research team will have access to these responses. Results will be
based on the answers given by all participants as a group, ensuring confidentiality of
individual responses. Group-based findings will be made available to those who are
interested. Your privacy will be protected to the maximum extent allowable by law.

Investigators will take measures to ensure the confidentiality of the participants by
eliminating names from interview transcriptions, data analyses documentation, and the
final project write up. Also, participation will be voluntary and you may withdraw from
participation at any time without penalty. Furthermore, you may refuse to answer
specific questions in the interview that you feel uncomfortable answering and can still be
a part of the study.

There are no known risks associated with participation in this study. Individually, you
will not benefit from your participation in this study, however future application of
research findings to the athletic training educational system will benefit future certified
athletic trainers. The more we know about the issues new certified athletic trainers face,
the more effectively we can structure the athletic training education programs.

Your participation in this research study would be greatly appreciated. If you have any

questions concerning your participation in this study, please contact Jennifer Stiller at
(517) 353-0728 or stillerj@msu.edu, or the principle investigator Dr. Daniel Gould at

119

(517) 432-0175 or drgould@msu.edu. The investigators may also be reached by mail at:
134 IM Sports Circle, Michigan State University, East Lansing, MI 48824.

If you have any questions or concerns regarding your rights as a study participant, or are
dissatisfied at any time with any aspect of this study, you may contact — anonymously, if
you wish — Peter Vasilenko, Ph.D., Director of Human Research Protections, (517) 355-
2180, fax (517) 432-4503, e-mail irb@msu.edu, mail 202 Olds Hall, Michigan State
University, East Lansing, MI 48824-1047.

Thank you for your time and cooperation,

 

 

Jennifer Stiller, MS, ATC Daniel Gould, PhD, Principle Investigator

Your signature below indicates your voluntary agreement to participate in this
study.

 

Participant Signature Date

Your signature below indicates your voluntary agreement to the audio taping of the
interview.

 

Participant Signature Date

This consent was approved by the Biomedical and Health Institutional Review Board
(BIRB) at Michigan State University. Approved 01-23-07 — valid through 01-22-08.
This version supersedes all previous versions. IRB#X06-1026.

120

Appendix E

121

Appendix E

Interview Guide for Study 2

Opening Questions

1.

2.

5.

For how many years have you been certified as ATC?

What types of undergraduate programs did you come from?

. What types of clinical athletic training experiences did you have while an

undergraduate?

. What types of administrative/communication responsibilities did you have in

undergraduate?

What are your present clinical and administrative responsibilities?

Open-Ended Questions for each “Probe” topic

What issues have you faced in the years since you’ve been out of undergrad? (e.g.,
interacting with, communicating with)
What were the most successful methods you found to handle these issues?
Did your undergrad program prepare you handle these types of issues?
How did they do so?
0 Scale 1-10: Based on your undergraduate preparation how prepared did you

feel to handle these issues when they arose?

Probes: Athletes

What types of issues have you had with athletes in terms of:
o Non-compliance; Reporting injuries in a timely fashion; Being unmotivated

during long—tenn rehab; Repairing a strained relationship with an athlete

122

Probes: Coaches
- What types of issues have you had with coaches & strength coaches in terms of:

o Informing them of athlete’s health/playing status (Athlete confidentiality
issues); Disagreements” regarding when athletes should return to activity;
Ability to communicate with them on a professional level

Probes: Doctors
I What types of issues have you had with doctors in terms of:

o Communicating on a professional level; Working relationship (two-way
respect with medical decisions); Getting athletes in to see doctor / having
doctor come to see your athletes; Having MD coverage at your games

0 Feeling informed on the status of your athletes; E-mail or telephone
communication

Probes: Parents
I What types of issues have you had with parents in terms of:
o Communicating athlete’s status (Athlete confidentiality issues); Parents
wanting to take child to see specialist at home: Explaining insurance issues
Open-Ended:
' What have you found to be the most effective ways of explaining injury to an athlete?
- What have you found to be the most effective ways of keeping your athlete compliant
in treatment and rehabilitation.
- What have you found to be the most effective ways to keep your athlete motivated in
rehab?
Strategies

° What type of training did you receive in your undergraduate program concerning:

123

Helping athletes set goals during rehabilitation
a. Do you do this now?
i. If yes, HOW -- if not, WHY NOT?
Strategies to keep athletes motivated during rehabilitation
Strategies to improve athlete compliance with treatment and rehabilitation
Visualization during healing
a. Do you do this now?
i. If yes, HOW -- if not, WHY NOT?
Relaxation
a. Do you do this now?
i. If yes, HOW -- if not, WHY NOT?
Cognitive techniques (thought-stopping, cognitive restructuring)
a. Do you do this now?
i. If yes, HOW -- if not, WHY NOT?
Assessment of athlete’s coping resources
a. Do you do this now?

i. If yes, HOW -- if not, WHY NOT?

Probes: Counseling

What type of training did you receive in your undergraduate program concerning:

0 Knowing when to refer for counseling ; Handling difficult athlete issues

I How well do you feel you handle these types of issues?

Probes: Social Support

What types of social support do you feel that you should provide in your role as an

athletic trainer?

124

Conclusion
What suggestions for improvement would you make to your undergrad to better prepare

you for your first few years in the “real world”?

125

Appendix F

126

Appendix F

Human Subjects Approval for Dissertation Study

An Evaluation of an Educational Intervention in Psychology of Injury
for Athletic Training Students
Informed Consent Form

WHY ARE YOU BEING INVITED TO TAKE PART IN THIS RESEARCH?
You are being asked to participate in this study because you are an athletic training
student in Michigan State University’s CAATE accredited undergraduate or graduate
athletic training education programs. This study is being conducted by Daniel Gould,
PhD and Jennifer Stiller, MS, ATC from Michigan State University.

WHAT IS THE PURPOSE OF THIS STUDY?
The purpose of this research is to evaluate the effectiveness of an educational
intervention designed to improve your knowledge in psychology of injury.

WHERE IS THE STUDY GOING TO TAKE PLACE AND HOW LONG WILL IT
LAST?

The research procedures will be conducted at Michigan State University. You will be
asked to participate in the study for the entire semester, however your active participation
in the educational module will only last for six weeks. The total amount of time you will
be asked to volunteer for this study is 7.5 hours over the next 20 weeks.

WHAT WILL YOU BE ASKED TO DO?

You will be asked to attend a two-hour workshop once a week for three weeks, then a 30-
minute seminar session once a week for three weeks. Both the workshop and the seminar
sessions will be held two evenings per week, and you may choose which night to attend.
At six points throughout the semester you will be asked to take a psychology of injury
knowledge test and a psychology of injury usage survey.

DO YOU HAVE TO TAKE PART IN THE STUDY?

If you decide to take part in the study, it should be because you really want to volunteer.
You can stop at any time during the study and still keep the benefits and rights you had
before volunteering.

WHO WILL SEE THE INFORMATION THAT YOU GIVE?

Only the primary investigators listed in this study and the Institutional Review Board will
see the information that you give. All research records that identify you will be kept
confidential. Your information will be combined with information from other people
taking part in the study. All published and presented accounts of this research will be
written based on the combined information that has been gathered. You will not be
identified in these written materials.

127

CAN YOUR TAKING PART IN THE STUDY END EARLY?

If you decide to take part in the study you still have the right to decide at any time that
you no longer want to continue. You will not be treated differently if you decide to stop
taking part in the study.

WHAT IF YOU HAVE QUESTIONS?

Before you decide whether to accept this invitation to take part in the study, please ask
any questions that might come to mind now. If you have any questions or concerns
regarding your rights as a study participant, or are dissatisfied at any time with any aspect
of this study, you may contact - anonymously, if you wish - Peter Vasilenko, Ph.D.,
Director of the Human Subject Protection Programs at Michigan State University, by
phone: (517) 355-2180, fax: (517) 432-4503, email: irb@msu.edu, or regular mail: 202
Olds Hall, East Lansing, MI 48824. We will give you a copy of this consent form to take
with you.

Than you for your time and cooperation,

 

 

Daniel Gould, PhD Jennifer Stiller, MS, ATC
Principle Investigator , Secondary Investigator

Your signature below indicates your voluntary agreement to participate in this
study and be video taped.

 

Participant Signature

This consent was approved by the Biomedical and Health Institutional Review Board
(BIRB) at Michigan State University. Approved 09/04/07 - valid through 06/05/08.
This version supersedes all previous versions. IRB#07-528

128

Appendix G

129

Appendix G
Applied Sport Psychology for Athletic Trainer Course Content and Schedule
Classroom Session 1
I Introduction to the course, course structure
I 3 key areas of psychology of injury research
I Antecedents (stress)
I Overview of research on antecedents
I Role of ATC pre-injury
I Emotional reactions
I ‘Normal’ and “abnormal’ emotional reactions
I ATC’s role as an informal counselor
I Psychology of athletic injury rehabilitation
I Communication in the athletic training room
I Building rapport
I 4 fundamentals of effective communication
I Key elements of communication skills within health care curriculum
I Practical communication skills
I Role play activity: injury scenario
I Communication “homework” assignment
I Clarifying expectations during injury and rehabilitation
I Introduction to pain (as both a physical and emotional experience)
I Rehabilitation progression, demands of rehabilitation

I Expectations ATCs have of athletes

130

I Facilitating rehabilitation adherence
I Gaining athletes’ cooperation
I Factors that influence athlete adherence
I Strategies for improving athlete adherence
I Importance of understanding the athlete’s sport
I Strategies for dealing with difficult or non-compliant athletes

I Role play activity: handling a difficult athlete

Classroom Session 2
I Social support in the athletic training room
I Definition and types of social support
I Injured athletes’ 4 main sources of social support
I Family, friends, significant others
I Support from coaches and teammates
I ATC—provided social support
I Practical social support provision strategies
I Social support “homework” assignment
I Social support from similar others

I Peer modeling interventions

131

I Motivational strategies
I Intrinsic versus extrinsic motivation related to rehabilitation
I Simple, practical motivation strategies
I Goal setting
I Types of goals (process, performance, outcome)
I Common mistakes in short-term goal setting
I ATC Toolbox: EZ Goal Form
I Dealing with failure to reach goals
I The research on goal setting

I Goal setting “homework” assignment

Classroom Session 3
I Introduction to psychological skills training (PST) used in injury rehabilitation
I Physiological techniques
I Relaxation (and techniques)
I Physiological effects of relaxation techniques
I Stress management (and techniques)
I Environmental engineering techniques
I Athlete stress management techniques
I ATC Toolbox: Centering
I Relaxation/centering “homework” assignment
I Cognitive techniques
I Typical post-injury thought process
I Introduction to self-talk (positive versus negative)

132

I The use of self-talk during injury rehabilitation
I Positive versus negative self-talk
I Techniques for controlling self-talk
0 Thought stopping
0 Cognitive restructuring
o Countering
o Reframin g
o Affinnation statements
0 “Rubberband” techniques
0 ATC Toolbox: Thought Stopping
I Imagery and athletic injury rehabilitation
I Research on imagery
I Characteristics of effective imagery
I Motivational, cognitive, healing imagery
I Combination of relaxation and guided imagery
I ATC Toolbox: Healing Imagery Scripts
I Use of imagery in injury rehabilitation
I Combining imagery and relaxation

I Cognitive techniques “homework”

133

I The ATC as a counselor
I Is counseling really our job?
I Effective injury counseling (the do’s and don’ts)
I Practical counseling “flow chart”
I Characteristics of the effective ATC-counselor
I Potential dual-role conflicts

I When and how to refer

Seminar Session 1
I Open-floor discussion of successes/challenges related to communication,
education, clarifying expectations, facilitating adherence, handling
difficulties/non-compliance
I Open-floor discussion of other participant-identified issues
I Journaling activity (due at Seminar Session 2)
I Self-check: interpersonal skills
I Do your athletes seem more comfortable with you now (versus
beginning of semester)? How comfortable are you talking to them
about (appropriate) non-sport related topics? Do athletes with new
injuries seem to come to you sooner?
I Assign follow-up assignment 1: goal setting follow-up (due at Seminar
Session 2)
I Did your athletes achieve their goals? If yes, how did you reward them?

If no, how did you reframe/revise goals?

134

Seminar Session 2
I Open-floor discussion of successes/challenges related to social support provision,
motivational strategies, use of goal setting
I Open-floor discussion of other participant-identified issues
I Follow-up assignment 1 and Journaling due TODAY: goal setting follow-up
I Journaling activity (due at Seminar Session 2)
I Self-check: what did you learn
I Think critically about what you Ieamed during this course. What
are some of the most valuable lessons that you have taken away?
I What were some of the most effective/successful strategies that
you have been able to implement with your athletes?
I What did you think of the in-class activities
I Emotional Response to Injury, Handling Difficult Athletes,
Goal Setting, Progressive Relaxation, Centering, Thought-
Stopping, Healing Imagery (comment on each individually)
I What did you think of the “homework” assignments?
I Initiating Conversations, Providing Social Support, Goal
Setting, Progressive Relaxation, Cognitive Techniques
(Imagery), MSU’s Referral Network
I What did you like about the class (please be as specific as
possible)?
I What did you dislike about the class (please be as specific as

possible), including any suggestions for improvement.

I35

I Assign follow-up assignment 2: PST follow-up (due at Seminar Session 3)
I Are they still using the PST techniques? Do they like them?
I If they are not using them, why not (didn’t buy in? Didn’t think it
worked? Didn’t want to put forth the effort? Lack of AT follow—up on

technique?)

Seminar Session 3
I Open-floor discussion of successes/challenges related to PST, informal
counseling interactions with athletes
I Open-floor discussion of other participant-identified issues
I Journaling activity due TODAY (participants turn in journals)

I Follow-up assignment 2 due TODAY: PST follow-up

136

Appendix H

137

Appendix H
Survey Development Methods

In order to evaluate the effectiveness of this educational intervention, one
knowledge test and two usage surveys were developed. Survey construction was
performed using the guidelines established by Raycov (2007). Each survey was a
subject-centered measurement, the goal of which is to the reveal the location of
individuals on a quantitative continuum with respect to a particular construct (e.g.,
communication skills, attentiveness to athletes), and to determine what level of mastery
or proficiency they possess in a particular subject area. Essentially, the purpose of each
study was to evaluate an individual to determine how well they implemented a given skill
set (e.g., communication, attentiveness) in the athletic training room.

The first step was to identify the primary purposes for which the test scores will
be intended. In this case, the purpose was to differentiate among individuals with regard
to a given construct in order to evaluate an underlying trait, the trait being knowledge and
skill in psychology of injury techniques. Behaviors were then identified that represented
the underlying construct (essentially defining the subject-matter domain of relevance).
The first step in this process was to engage in content analysis, whereby open-ended
questions were posed to recently certified athletic trainers and to collegiate student-
athletes (Chapter 3). Responses were sorted into topical categories, with the predominant
categories among their answer forming the major components of the construct to be
assessed. These categories served as a basis for generating survey items. A critical
review of the literature was next undertaken, the purpose of which was to identify
behaviors most frequently studied by others in the field. This information, combined

with personal experience and direct observation of other athletic trainer-athlete

138

interactions, was used to generate additional items. Once an initial pool of items had
been compiled, input was solicited from experts in the field to help narrow and refine the
types of behavior pertaining to the construct. Experts for the athletic training and athlete
surveys included three ATCs with a combined 14 years of experience, one Association
for Applied Sport Psychology (AASP) certified sport psychology specialist with 30 years
of experience. and one ATC/sport psychology specialist with 8 years of experience
(Panel A).

Once subject matter was identified, the proportion of items focusing on each type
of behavior in the construct was delineated. The decision about relative weights of the
sub-scales was based on qualitative data collected previously from collegiate student-
athletes and recently certified athletic trainers, as well as the combined perceptions of the
experts within the field. It was determined that the initial survey instruments should
consist of questions relating to the following latent constructs (percent of questionnaire in
parentheses): communication (20%), social support (25%), relationship development
(20%), attitude and attentiveness ( 10%), motivation and goal setting (15%), and sport
psychology in the athletic training room (10%). The construct of sport psychology in the
athletic training room was comprised of items related to imagery, relaxation, self-talk,
and cognitive restructuring. An initial pool of items was then constructed: 62 for the P01-
U, and 85 for the POI-T (see Appendices E and F). The format of all items was a 9-
choice Likert scale with response scales ranging either from strongly disagree (1) to
strongly agree (9), or from never (1) to always (9). The initial survey instruments were
reviewed for accuracy by experts in the field, and were reviewed for wording and

ambiguity by subjects in the target population.

139

The initial survey instruments were field tested with 215 athletic training students
and 216 collegiate student-athletes. The pools of pilot test subjects were within the target
population (junior-level, senior-level, and graduate ATS and collegiate student-athletes),
but did not include subjects who would be using the final survey instrument. Comments
were invited from these pilot test subjects on how they perceived each item, and these
suggestions were considered when developing the final survey instrument. The final
questionnaires are included in Appendices K and L.

Descriptive statistics for response distribution of initial survey instruments were
generated for each question, the purpose being to determine if there was sufficient
variation in the responses to discriminate between subjects. The maximum likelihood
method of exploratory factor analysis (EFA) was conducted to verify that all questions in
each sub-scale measured the same latent variable (e .g., motivation, attentiveness,
communication). One latent factor was found to underlie all questions contained within
each of the six subscales (communication, social support, motivation, relationship,
attitude and attentiveness, and sport psychology). Questions that loaded least on these
factors were removed, both to improve validity and reliability, and to decrease the length
of the test. Reliability testing was performed on each subscale, with all reliability
coefficients 0.627 or higher (range: 0.627—0.91 l for athlete survey; range: 0716-0894 for
athletic training student survey) and all cronbach alpha 0.657 or higher (range: from
0762-0910 for athlete survey; range:0.657-0.894 for the athletic training student
survey). No items were deleted to improve alpha. Complete results of factor analysis
and reliability testing are presented in Table H.1 and H2. Confirmatory factor analysis

(CFA) was not conducted due to the pilot sample size.

140

Content validity was evaluated for each survey, which is essentially a “conceptual
test” of whether a given instrument evaluates what it is presumed to measure. In order to
establish content validity, a substantive domain to be measured must be determined (e .g.,
communication, attitude). This was established through review of the literature and
content analyses (Chapter 2 and 3). Content validity is a qualitative type of validity that
depends on the theoretical definition of the domain being studied (2007). To evaluate
content validity in this context, a group of independent experts was impaneled to judge
whether items on the surveys adequate sampled the domain of interest (Panel A).

Because there was no existing survey (criteria) with which to compare the athlete
or athletic training student surveys, criterion validity could not be evaluated. An attempt
at construct validation was attempted. Correlation between matching subscales on the
athlete and athletic training student surveys were calculated. These correlations were
very low (range: 0.05—0.17), which was hypothesized to be due to the fact that pilot
subjects for the two surveys came from two completely unrelated populations.
Confirmatory factor analysis is an acceptable test of construct validity, however this
could not be conducted due to the pilot sample size. However, we can make some
inferences about content validity based on the unidimensionality of all scales as shown by

EFA; however, these models were not tested definitely through CFA.

141

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142

APPENDIX I

143

APPENDIX I

ORIGINAL PSYCHOLOGY OF INJURY USAGE SURVEY (POI-U)

Athletic Training Students’ Use of Communication and
Applied Sport Psychology with Injured Athletes

As you are answering these questions, please keep in mind that the purpose of this
survey to is evaluate what IS being done in the athletic training room. not what SHOULD
be done. While it may be socially desirable to answer a certain way, please answer
questions based on your actual behaviors in the athletic training room.

Please indicate your current year in your athletic training education program.
Second Year in Program (Junior Level)
Third Year in Program (Senior Level)
Fourth Year in Program (5'h Year Senior Level)

All questions are scored on a 9—point Likert scale:

 

 

1. I explain injuries in terms and language that my athletes can understand.

2. I try to make my athletes feel comfortable talking to me about issues unrelated to
injury or sport

3. I remind my athletes that there will be highs and lows in progress during rehabilitation.
4. I come up with creative ways to motivate my athletes during rehabilitation.

5. I have a positive attitude when I am in the athletic training room.

6. I show interest in my athletes as people (outside of sport).

7. I educate my athletes about outside resources that are available to them.

8. I encourage my athletes to use visualization & imagery during injury and
rehabilitation.

9. I recognize and compliment my athletes for the effort they are putting into treatment
and rehabilitation

l0. I am able to develop a rapport (carry on a conversation) with most of my athletes.
l l. I am effective at motivating athletes in long-term rehabilitation.

12. I express or demonstrate negative feelings or opinions about athletes in the presence
of other athletes.

13. I explain to my athletes how the exercises they are doing will help them return to their
sport more quickly.

14. I teach and encourage athletes to use thought-stopping during injury and
rehabilitation.

15. I explain to my athletes how accomplishing each goal will help them return to sport.
16. I am able to challenge my athletes to work harder without yelling at them.
17. I explain to athletes the progression they can expect during rehabilitation.

18. I tend to not work as hard with the athletes who I am sure are faking injuries or
blowing minor injuries out of proportion.

19. I know things about my athletes outside of sport.
20. I help my athletes find something positive in any situation.
2| . The rehabilitation goals that I set are meaningful to the athlete.

22. I teach and encourage athletes to use relaxation techniques during injury and
rehabilitation.

23. l monitor or pay attention to athletes when they are rehabilitating
24. I am friendly and approachable the first time I interact with an athlete.

25. I take care of my athletes’ needs (e.g., providing physical assistance, rides to doctor
appointments)

26. I make sure that my athletes know what to expect during the course of their injury
(pain. range of motion, function, etc).

27. I explain the purpose of the exercises or treatments that I am having my athlete do.

28. I encourage my athletes to express their feelings and emotions about their injury

145

29. 1 provide athletes with objective (#’s) feedback on their progress on a regular basis.
30. I can tell when an athlete is having a bad day.
31. I show my athletes respect.

32. I explain treatments and exercises in terms and language that my athletes can
understand.

33. I allow my athletes to vent without judging them

34. I teach and encourage athletes to use cognitive restructuring techniques during injury
and rehabilitation.

35. I develop creative rehabilitation programs.

36. When I notice that an athlete seems to be focused on the possibility of re-injury, I
remind him/her to trust that the rehabilitation program was successful.

37. I consider myself to be effective at motivating athletes during the low points
(setbacks, bad weeks) in rehabilitation.

38. I play favorites with players on my team.

39. I am able to challenge and motivate my athletes when they are not putting enough
effort into rehabilitation.

40. I use healing imagery scripts with my athletes.

41. I am able to listen to athletes without giving advice.

42. 1 outline a progression (series, list) of short-term goals for my athletes.

43. I work with my athletes one-on-one.

44. I do a good job of getting to know both uninjured and injured athletes on my team.
45. I fit in with my team.

46. I make sure my athlete knows what to expect after a new injury or surgery.

47. I express concern about the condition of my athletes.

48. I confront athletes when they skip a treatment or rehabilitation session.

4

\O

. I help my athletes set short-term goals.

I46

50. I consider myself a trustworthy person to whom my athlete could turn to for advice.
51. I explain to my athletes how being tense can hinder success in rehabilitation.

52. I explain the purpose of the modality that I am using with my athlete.

53. I teach athletes how to monitor their negative self-talk during injury and rehabilitation
54. I encourage my athletes to express their feelings and emotions about their injury.

55. I explain the purpose of the exercises or treatments that I am having my athlete do.

56. 1 am able to challenge my athletes’ negative emotions when they are interfering with
their rehabilitation progress.

57. I am able to connect with most of my athletes on a personal level.

58. 1 encourage athletes to play an active role in developing rehabilitation tasks and
exercises.

59. I keep my personal life out of the athletic training room.
60. I help my athletes see the “big picture” and put their injury into perspective.
6l. 1 tell my athletes what they can do to help speed their recovery.

62. I act negatively towards certain athletes on my team.

I47

APPENDIX J

148

APPENDIX J
ORIGINAL PSYCHOLOGY OF INJURY TRANSFER SURVEY (POI-T)
Evaluation of Your Experiences in the Athletic Training Room

As you are answering these questions, please keep in mind that the purpose of this

survey is to evaluate what IS being done in the athletic training room, not what SHOULD
be done. The results of this study will be used to help athletic training students learn how
they can better meet your needs as a student-athlete. Remember that your name, school,
or other personal information will NOT be tied to your responses; your responses will
remain totally anonymous.

All questions are scored on a 9-point Likert scale:

 

Almost About Half Almost

 

9.

My athletic trainer explains injuries in terms and language that I can understand.
My athletic trainer is understanding when I have a bad day

Having my athletic trainer yell at me is an effective motivation strategy. (reverse
scale)

I feel comfortable talking to my athletic trainer about issues unrelated to injury or
sport.

I imagine myself working successfully through tough situations (further injury, slow
rehabilitation).

My athletic trainer reminds me that there will be highs and lows in progress during
rehabilitation.

My athletic trainer comes up with creative ways to motivate me during rehabilitation.

My athletic trainer maintains a positive attitude when he/she is in the athletic training
room.

My athletic trainer shows interest in my as a person (outside of sport).

10. My athletic trainer educates me about outside resources that are available to me.

149

ll.

l3.

I4.

15.

l6.

I7.

18

I9.

20.

21.

22.

23.

I like my athletic trainer as a person.

. It was difficult for me to do exactly what the athletic trainer told me to do.

My athletic trainer encourages me to use visualization & imagery during injury and
rehabilitation.

My athletic trainer notices and recognizes the effort I put into treatment and
rehabilitation.

My athletic trainer is able to carry on a conversation with me.
I imagine myself coping with (dealing with) the stress associated with my injury.

My athletic trainer can keep me motivated during long—term (extended) rehabilitation.

. My athletic trainer says negative things about other athletes on my team. (reverse

scale)

My athletic trainer helps me to see how the exercise I am doing will help me return to
my sport more quickly.

I find myself thinking negative thoughts about my injury.

My athletic trainer shows me how accomplishing each goal will help me return to my
sport.

My athletic trainer allows me to say everything I wanted about my injury

I respect my athletic trainer as a professional.

24. To get me to work harder during rehabilitation, my athletic trainer yells at me.

25.

26.

27.

28.

29.

(reverse scale)
My athletic trainer explains the progression I can expect during my rehabilitation.

Even before I start a rehabilitation exercise. I can imagine (visualize) myself
completing it perfectly).

My athletic trainer acts like he/she thinks I am faking an injury or blowing an injury
out or proportion. (reverse scale)

My athletic trainer knows things about me outside of my sport.

My athletic trainer is too pushy in trying to learn about my personal life. (reverse
scale)

150

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

41..

42.

43.

45.

47.

48.

My athletic trainer is too pushy in trying to learn about my personal life. (reverse
scale)

My athletic trainer helps me find something positive in any situation.
My athletic trainer seems to take my problems seriously.

My athletic trainer makes rehabilitation goals meaningful to the me.
I consider my athletic trainer a friend.

I find myself saying negative things to myself about my injury.

I imagine my body repairing itself.

My athletic trainer teaches and encourages me to use relaxation techniques during
injury and rehabilitation.

My athletic trainer tells me all that 1 want to know about my injury.

My athletic trainer monitors me or pays attention to me when I am rehabilitating

. My athletic trainer was friendly and approachable the first time I interacted with

him/her.

My athletic trainer takes care of my needs (e.g., providing physical assistance, rides
to doctor appointments)

My athletic trainer makes sure that I know what to expect during the course of my
injury (pain, range of motion, function, etc).

My athletic trainer explains the purpose of the exercises or treatments that they ask
me to do.

. My athletic trainer encourages me to express my feelings and emotions about my

injury.

I feel comfortable talking about my problems (injury-related or personal) with my
athletic trainer.

. My athletic trainer provides me with objective (#’s) feedback on my rehabilitation

progress (e.g., range of motion, strength).
My athletic trainer can tell when 1 am having a bad day.

My athletic trainer shows me respect.

151

49.

50.

51.

52.

53.

My athletic trainer explains treatments and exercises in terms and language that I can
understand.

I know that I can vent to my athletic trainer when I need to. and that they won’t judge
me for what I say.

My athletic trainer teaches me ways to change negative thoughts that I have about my
injury.

I think my athletic trainer is good at his/her job.

I imagine each rehabilitation exercise outside of the athletic training room.

54. My athletic trainer is very creative with coming up with new activities for my

55.

56.

57.

58.

59.

61.

62.

63.

65.

rehabilitation (so I am not bored).

I work harder when my athletic trainer yells at me. (reverse scale)

When I start thinking about the possibility of getting re-injured (or when I am nervous
about going back to my sport for the first time), my athletic trainer encourages me to

trust in the success of my rehabilitation program.

My athletic trainer is effective at motivating me during the low points (setbacks, bad
weeks) in rehabilitation.

My athletic trainer plays favorites with players on my team. (reverse scale)

My athletic trainer knows how to challenge and motivate me when he/she sees that I
am not putting my full effort into rehabilitation.

. My athletic trainer encourages me to use visualization & imagery during injury and

rehabilitation.
My athletic trainer is willing to listen to me without giving advice.
My athletic trainer explains procedures to me so that I knew what to expect.

My athletic trainer outlines a progression (series, list) of goals that I must achieve
before I will be ready to return to my sport.

. When my athletic trainer yells at me for not working hard enough during

rehabilitation, it makes me want to give up and stop trying. (reverse scale)

I feel like I can turn to my athletic trainer in times of stress.

. My athletic trainer works with me one-on—one.

152

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

82

83.

84.

85.

86.

My athletic trainer does a good job of getting to know both uninjured and injured
athletes on my team.

1 think my athletic trainer fits in with my team.
My athletic trainer tells me what to expect after a new injury or surgery.
My athletic trainer expresses concern about me as a person.

My athletic trainer knows how to confront me when I skip a treatment or
rehabilitation session.

My athletic trainer helps me set goals for things I want to accomplish during rehab.
My athletic trainer is a trustworthy person I could turn to for advice when I need it.
My athletic trainer explains how being tense can prevent doing my exercises well.

My athletic trainer explains the purpose of the modality (e.g., e-stim, ultrasound) that
I am using.

My athletic trainer teaches me ways to stop saying negative things to myself about
my injury.

My athletic trainer encourages me to express my feelings and emotions about my
injury.

My athletic trainer helps me understand the purpose of the exercises or treatments
that I am doing.

My athletic trainer is able to challenge my negative emotions.
My athletic trainer is able to connect with me on a personal level.

My athletic trainer asks for my help in developing sport-specific rehabilitation.

. My athletic trainer keeps his/her personal life out of the athletic training room.

I imagine (visualize) the physiological changes occurring in my body during healing
(such as swelling decreasing or my muscle being repaired).

My athletic trainer helps me see the “big picture” and puts my injury into perspective.
My athletic trainer makes sure that 1 know what I can do to help speed my recovery.

My athletic trainer acts negatively towards some athletes on my team.

153

APPENDIX K

154

APPENDIX K
FINAL PSYCHOLOGY OF INJURY USAGE SURVEY (POI-U)

Athletic Training Students’ Use of Communication and
Applied Sport Psychology with Injured Athletes

As you are answering these questions, please keep in mind that the purpose of this
survey to is evaluate what IS being done in the athletic training room, not what SHOULD
be done. While it may be socially desirable to answer a certain way, please answer
questions based on your actual behaviors in the athletic training room.

Please indicate your current year in your athletic training education program.
Second Year in Program (Junior Level)
Third Year in Program (Senior Level)
Fourth Year in Program (5“1 Year Senior Level)

All questions are scored on a 9—point Likert scale:

 

Almost About Half Almost

 

1. I try to make my athletes feel comfortable talking to me about issues unrelated to
injury or sport

2. I have a positive attitude when I am in the athletic training room.

3. I show interest in my athletes as people (outside of sport).

4. I encourage my athletes to use visualization & imagery during injury and
rehabilitation.

5. I recognize and compliment my athletes for the effort they are putting into
treatment and rehabilitation

6. I am able to develop a rapport (cany on a conversation) with most of my athletes.

7. I ask for athlete input in setting goals for the rehabilitation program.

155

10.

ll.

12.

l3.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

I explain to my athletes how the exercises they are doing will help them return to
their sport more quickly.

I teach and encourage athletes to use thought-stopping during injury and
rehabilitation.

I explain to my athletes how accomplishing each goal will help them return to
sport.

I am able to challenge my athletes to work harder without yelling at them.

I explain to athletes the progression they can expect during rehabilitation.

I know things about my athletes outside of sport.

I help my athletes find something positive in any situation.

I teach and encourage athletes to use relaxation techniques during injury and
rehabilitation.

1 monitor or pay attention to athletes when they are rehabilitating

I make sure that my athletes know what to expect during the course of their injury
(pain, range of motion, function, etc).

I explain the purpose of the exercises or treatments that I am having my athlete
do.

1 encourage my athletes to express their feelings and emotions about their injury
I provide athletes with objective (#’s) feedback on their progress on a regular
basis (e.g., range of motion, strength).

I can tell when an athlete is having a bad day.

I show my athletes respect.

I explain treatments and exercises in terms and language that my athletes can

understand.

156

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

I allow my athletes to vent withoutjudging them.

I teach athletes how to monitor their negative self-talk during injury and
rehabilitation.

I am able to challenge and motivate my athletes when they are not putting enough
effort into rehabilitation.

1 use healing imagery scripts with my athletes.

I outline a progression (series, list) of short—term goals for my athletes.

I work with my athletes one-on—one.

I do a good job of getting to know both uninjured and injured athletes on my
team.

I help my athletes set short—tenn goals.

I consider myself a trustworthy person to whom my athlete could turn to for
advice.

I explain to my athletes how being tense can hinder success in rehabilitation.

I explain the purpose of the modality that I am using with my athlete.

I teach and encourage athletes to use cognitive restructuring techniques during
injury and rehabilitation.

I encourage athletes to play an active role in developing rehabilitation tasks and

exercises.

157

APPENDIX L

158

APPENDIX L

FINAL PSYCHOLOGY OF INJURY TRANSFER SURVEY (POI-T)

Evaluation of Your Experiences in the Athletic Training Room

As you are answering these questions, please keep in mind that the purpose of this
survey is to evaluate what IS being done in the athletic training room, not what SHOULD
be done. The results of this study will be used to help athletic training students learn how
they can better meet your needs as a student-athlete. Remember that your name. school.
or other personal information will NOT be tied to your responses; your responses will
remain totally anonymous.

All questions are scored on a 9—point Likert scale:

 

Almost About Half Almost

 

1. My athletic trainer explains injuries in terms and language that I can understand

2. My athletic trainer is understanding when I have a bad day.

3. I feel comfortable talking to my athletic trainer about issues unrelated to injuries or
sports.

4. My athletic trainer comes up with creative ways to motivate me during rehabilitation.

5. My athletic trainer maintains a positive attitude around all athletes when in the
athletic training room.

6. My athletic trainer shows interested in me as a person (outside of sport).

7. My athletic trainer helps me to see how the exercise I am doing will help me return to

my sport more quickly.

159

10.

11.

12.

13.

14.

15.

l6.

17.

18.

I9.

20.

21.

22.

23.

My athletic trainer shows me how accomplishing each goal will help me return to my
sport.

My athletic trainer explains the progression I can expect during my rehabilitation.
My athletic trainer makes rehabilitation goals meaningful to me.

My athletic trainer teaches and encourages me to use relaxation techniques during
injury and rehabilitation.

My athletic trainer monitors me or pays attention to me when I am rehabilitating.
My athletic trainer was friendly and approachable the first time we interacted.

My athletic trainer notices and recognizes the effort I put into treatment and
rehabilitation.

My athletic trainer provides me when objective (#5) feedback on my rehabilitation
progress (e.g., range of motion, strength).

My athletic trainer can tell when I am having a bad day.

My athletic trainer shows me respect.

My athletic trainer teaches me ways to change negative thoughts that I have about my
injury (e.g., reframing, countering).

My athletic trainer changes and adds new activities to rehabilitation (so I am not
bored).

My athletic trainer works with me one-on-one.

My athletic trainer is effective at motivating me during the low points (setbacks, bad
weeks) in rehabilitation.

My athletic trainer knows how to challenge and motivate me when I am not putting
my full effort into rehabilitation.

My athletic trainer explains procedures to me so 1 know what to expect.

160

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

When I start thinking about getting re—injured (or when I am nervous about going
back to my sport for the first time), my athletic trainer encourages me to trust in the
success of my rehabilitation program.

My athletic trainer does a good job getting to know both uninjured and injured
athletes on my team.

My athletic trainer tells me what to expect after a new injury or surgery.

My athletic trainer helps me set goals for events I want to accomplish during
rehabilitation.

My athletic trainer explains how being tense can prevent me from doing my exercises
well.

My athletic trainer teaches me to use thought stopping to stop negative thoughts about
my injury.

My athletic trainer encourages me to express my feelings and emotions about my
injury.

My athletic trainer is able to challenge my negative emotions and attitudes in
rehabilitation.

My athletic trainer is able to connect with me on a personal level.

My athletic trainer asks for my help in developing sport-specific rehabilitation
exercises.

I imagine my body healing itself(such as swelling decreasing or my muscle being

repaired).

161

APPENDIX M

162

10.

11.

12.

13.

14.

APPENDIX M

PSYCHOLOGY OF INJURY KNOWLEDGE TEST (POI-K)

. List 3 guidelines for the psychological management of pain.

What are the 3 major areas that affect the stress response?

. What are the 2 basic mechanisms behind the stress/injury relationship?

List and briefly describe the 2 types of stressors.

. Give an example of positive and negative self-talk.

Research has identified several important results of effective athlete-athletic trainer
communication. Please list two reasons why this communication is so important.

What are 2 fundamentals of effective injury communication?

Please list 2 practical communication skills.

Providing information and clarifying expectations during rehabilitation serves several
important purposes; please list two such purposes.

List 2 strategies to improve adherence.

List 2 strategies for dealing with non—compliant or difficult athletes.

What are 3 types of social support and provide 1 practical provision example of each.

What are the athlete’s 4 major groups of social support providers?

What are 2 benefits of ATC-provided social support?

163

15.
l6.
17.
18'.
19.

20.

21.

22.

23.
24.

25.

26.

27.

28.

Please list 2 practical motivation strategies.

What is 1 theory of how goal setting increases performance?

Please write one example of a goal that fits all the components of an effective goal.

What are the 3 types (categories) of goals?

What are 2 common mistakes in goal setting?

How should you deal with an athlete who has not reached his/her goal by the
“deadline”?

Choose 1 stress management technique and explain how you would implement it with
an athlete.
List and explain 1 technique for controlling self-talk

What are 2 characteristics of effective imagery?

What are the 3 types (categories) of imagery and provide 1 example of each.

There are situations that are psychological in nature in which it would be appropriate
to refer an athlete for further counseling with a professional and situations in which it
is not necessary to make a referral. Please describe a circumstance for each situation.

Describe a situation in which a conflict may arise due to providing services in a dual
role as both a sport psychologist and athletic trainer.

What are four characteristics of an effective ATC-counselor?

Why is an emotional attachment of an athlete problematic for effective counseling?

I64

APPENDIX N

165

APPENDIX N

KEY TO PSYCHOLOGY OF INJURY KNOWLEDGE TEST (POI-K)

1. List 3 guidelines for the psychological management of pain.
a. At occurrence of injury:
' Establish rapport and create positive realistic expectations
0 Shift focus from pain to thoughts of a positive outcome or to the
next step in injury management
b. During otherwise uncomplicated rehabilitation:
° Educate athlete regarding the mechanisms of injury and
treatment
° Identify pain as a routine aspect of rehabilitation
c. With treatment plateaus or setbacks
° Clarify treatment goals and encourage conscientious adherence
° Reassume athlete of the benign status of pain
d. At failed return to play:
0 Acknowledge discouragement and provide support
° Differentiate routine pain from dangerous pain (which signals
reinjury)
e. Chronically failed rehab:
0 Treat pain complaints as read even if inconsistent
' Review the rehabilitation program with respect to all factors

identified above, searching for mitigating or sabotaging factors

I66

2. What are the 3 major areas that affect the stress response?
f. Stress history, personality factors, coping resources
3. What are the 2 basic mechanisms behind the stress/injury relationship?
g. Increased generalized muscle tension, decreased attention during stress,
decreased coordination and skill
4. List and briefly describe the 2 types of stressors.
h. Life events (eg, death, marriage, significant other breakup, moving)
i. Daily hassles (everyday stressors and strains of living that may/may not be
connected to major life events)
5. Give an example of positive and negative self-talk.

° Positive self talk: I can beat the odds and recovery sooner than normal, it is
getting better all the time, getting through this will make me a stronger person,
how can 1 make the most out of the situation?

0 Negative self talk: Recovering will take forever, I will never make up for lost
time, I will never be as strong again, stupid injury, stupid leg, there is nothing I
can do about it, why me?

6. Research has identified several important results of effective athlete-athletic trainer
communication. Please list two reasons why this communication is so important.
° Essential for rehab adherence
° Important for successful coping
' Essential for healing process
0 So information is transferred

' Providing reassurance promotes positive attitude toward recovery

167

Need to communicate expectation that the athlete is responsible for his/her
own treatment and recovery

Help athlete accept they are injured

Help athlete realize that they will recover with hard work

Convince athlete that you (AT) will help them through the difficult tasks
ahead

Explain that sensations they will likely experience are natural responses to
being injured

Help athlete develop self-confidence and self-reliability

7. What are 2 fundamentals of effective injury communication?

Develop credibility
Communicate with positive approach
Send messages high in information

Communicate with consistency

8. Please list 2 practical communication skills.

Allow athlete to talk and share

Be available when assistance is needed

Display a positive attitude (verbal, body language)
Treat the athlete as an individual

Let the athlete know what to expect during recovery

168

9. Providing information and clarifying expectations during rehabilitation serves several

important purposes; please list two such purposes.

Decreases anxieties by answering unasked questions

Communicate expectation that athlete should play active role

Eases fears that generally arise when unknown sensations are encountered
Provides peace of mind and a sense of control

Pain information (good vs bad pain, level that indicates they should stop)
Let them know they should expect highs, lows, setbacks, and plateaus

So they understand the time commitment & EFFORT that is required

10. List 2 strategies to improve adherence.

Send clear, concise messages that are high in information
Plan rehabilitation sessions around the athlete’s schedule
Make rehabilitation challenging

Personalize treatment

Offer variety in treatment

Know the sport

Assist with goal setting

Offer encouragement, support system

I 1. List 2 strategies for dealing with non-compliant or difficult athletes.

0 Do not get into a battle of wills

0 Develop a plan WITH the athlete (input in goal setting)

0 Reinforce any/all positive thinking and comments

0 Agree with their perceptions & reframe — get athlete to contribute

I69

12. What are 3 types of social support and provide 1 practical provision example of
each.
0 Listening Support
o Vent without judging; allow athletes to describe sensations — athletes
know their bodies best
' Emotional Support
0 Help athlete acknowledge existence and severity of injury; encourage
expression of emotions following injury; prevent dwelling over
setbacks or lack of progress
0 Emotional Challenge
0 Help redirect emotions into things athlete can control!
0 Reality Confirmation
0 You are NOT in same reality ~— put things back into perspective
0 Personal and Tangible
0 Provide rides and physical assistance devices (e.g., crutches) when
possible; communicate with coaches; be flexible with rehabilitation
appointments 1
0 Task Appreciation
0 Write a card or pull the athlete aside; acknowledge athlete effort
0 Task Challenge
0 Challenge athlete to act, and make them accountable; work out with
athlete (opportunity for competitive spirit to come out); make rehab

challenging/sport specific; push to do as much as safely possible

170

' Information Support
0 Provide as much information as possible; make sure athletes know
what to expect; reassure athlete of success of rehabilitation; reduce
fear of over-stressing injured part and of re-injury; help athlete set
realistic performance goals; analyze athlete’s sport technique and
training; make suggestions with regard to the injury; provide explicit
instruction about what athlete can/cannot do when beginning return to
activity
13. What are the athlete’s 4 major groups of social support providers?
° Family, friends, significant others
' Coaches, teammates
° ATCs and sports medicine team
' Similar others
14. What are 2 benefits of ATC-provided social support?
' Increases athlete’s self-efficacy
' Decreases athlete’s anxiety
° Enhances rehabilitation adherence and compliance
° Influences beliefs about the success/effectiveness of the rehabilitation
program

' Influences perceived susceptibility of re-injury

171

15. Please list 2 practical motivation strategies.
0 Regular monitoring and supervision
' Provision of feedback; elicit feedback from athletes
' Write card/pull athlete aside
° Participate in exercises
' Goal setting

16. What is l theory of how goal setting increases performance?
° Mobilizes effort

' Directs attention

Develops new Ieaming strategies

Increases motivation

Prolongs persistence
17. Please write one example of a goal that fits all the components of an effective goal.

° SMART (specific, measurable, adjustable, realistic, timeframe)
18. What are the 3 types (categories) of goals?

0 Process goals, performance goals, outcome goals
19. What are 2 common mistakes in goal setting?

° Failure to set meaningful goals

° Setting too many goals too soon

° Focusing on outcome or long-term goals only

' Failure to record goals

' Failure to monitor progress

0 Failure to re-evaluate goals

I72

20. How should you deal with an athlete who has not reached his/her goal by the

“deadline”?

Acknowledge discouragement, frustrations. Ask athlete if he/she satisfied
all process/performance goals during the timeframe (yes: adjust goals

appropriately, no: adjust process/performance goals)

21. Choose 1 stress management technique and explain how you would implement it

with an athlete.

Environmental engineering (schedule rehab when coach not around)
Progressive relaxation
Monitoring self-talk

Centering

22. List and explain 1 technique for controlling self-talk

Thought stopping

Cognitive restructuring (change negative to positive)
Countering (refute underlying beliefs with facts/reasoning)
Reframing (creating different ways of looking at it)

affirmation statements (post meaningful statements, focus on right thing)

Rubberband

23. What are 2 characteristics of effective imagery?

Vivid, simple, specific
Use all senses
Practiced in many places, positions

Practiced until you can image in real time

173

24.

25.

26.

27.

28.

What are the 3 types (categories) of imagery and provide 1 example of each.
0 Cognitive (increases comfort, confidence, focuses attention)
' Motivational (replay imagery, seeing self complete exercise)
' Healing (visualize some aspect of healing process)
There are situations that are psychological in nature in which it would be appropriate
to refer an athlete for further counseling with a professional and situations in which it
is not necessary to make a referral. Please describe a circumstance for each situation.
' Referral situations: eating disorders, psychological problems (depression)
' Non-referral situations: mild malingering, distress over becoming injured,
problems dealing with the injury
Describe a situation in which a conflict may arise due to providing services in a dual
role as both a sport psychologist and athletic trainer.
' Primarily confidentiality issues, time management
What are four characteristics of an effective ATC-counselor?

° Effective listening skills/ accessibility; positive attitude; ability to help
athletes set realistic goals; treats the athlete as an individual; has the ability to
education; has the ability to motivate the athlete; has an understanding of own
professional limits

Why is an emotional attachment of an athlete problematic for effective counseling?

' Lose objectivity

174

Expert Panel:

Tracey Covassin, Ph.D., A.T.C.

Undergraduate Athletic Training Education Program Director
Michigan State University

East Lansing, MI

Crystal Branta, Ph.D.

Associate Professor, Department of Kinesiology
Michigan State University

East Lansing, MI

Daniel Gould, Ph.D.
Director, Institute for the Study of Youth Sports

Michigan State University
East Lansing, MI

Martha Ewing, Ph.D.
Associate Professor, Department of Kinesiology Michigan State University
East Lansing, MI

John Ostrowski, M.S., A.T.C.
Assistant Athletic Trainer

The College of the Holy Cross
Worcester, MA

175

APPENDIX 0

I76

APPENDIX 0

RESULT TABLES FROM CHAPTER 4

Table 0.1. Baseline and Follow-up POI-K Means and Standard Deviations
(Hypothesis 1)

 

 

Group Mean SD N
Baseline POI-K Group B 14.2813 7.08277 16
Group A 18.3667 8.44830 15
Total 16.5281 7.91820 3 1
Week 3 POI—K Group B 18.2813 7.11798 16
Group A 44.0667 10.45546 15
Total 30.7581 15.74583 3 1
Week 6 POI-K Group B 16.3438 6.18255 16
Group A 49.8667 12.85977 15
Total 32.5645 19.65441 3 1

 

Table 0.2. Box M Test for Equality of Covariance Matrices from RMA for Hypothesis 1

 

 

Box’s M 13.497

F 1 .995

dfl 6

df2 6016.462
Significance .063

 

Note. All Box M Tests test the null hypothesis that the observed covariance matrices of
the dependent variables are equal across groups.

Table 0.3. Levene’s Test of Equality of Error Variances from RMA for Hypothesis 1

 

 

F dfl df2 Significance
Baseline POI—K .817 1 29 .374
Week 3 POI-K 2.455 1 29 .128
Week 6 POI-K 2.950 1 29 .097

 

Note. All Levene’s Tests test the null hypothesis that the error variance of the dependent
variable is equal across groups.

177

Table 0.4. Mauchly’s Test of Sphericity from RMA for Hypothesis 1

 

 

Epsilon
Within Mauchly's Approx Greenhouse- Huynh- Lower-
Subjects Effect W Chi-Square df Sig. Geisser Feldt bound
TIME 0.784 6.817 2 .033 0.822 0.895 0.5

 

Note. All Mauchly’s Tests test the null hypothesis that the error covariance matrix of the
orthonormalized transformed dependent variables is proportional to an identity matrix

Table 0.5. Baseline and Follow-up POI—K Means and Standard Deviations
(Undergraduate Students Only)

 

 

Group Mean SD N
Baseline POI-K Group B 13.9333 7.18845 15
Group A 16.4091 8.41967 1 1
Total 14.9808 7 .67 135 26
Week 3 POI—K Group B 18.0667 7.31404 15
Group A 42.4545 10.29431 1 1
Total 28.3846 14.94419 26
Week 6 POI-K Group B 16.3438 6.18255 15
Group A 49.8667 12.85977 1 1
Total 32.5645 19.65441 26

 

Table 0.6. RMA Multivariate Output for POI-K (Undergraduate Students Only)

 

 

Effect Value F Hypothesis Error Sig Partial Eta
(If (If Squared

Time Pillai’s Trace .797 45.228 2.000 23.000 .000 .797
Wilks’ Lambda .203 45 .228 2.000 23 .000 .000 .797
Hotelling’s Trace 3.933 45 .228 2.000 23 .000 .000 .797
Roy’s Largest Root 3.933 45 .228 2.000 23 .000 .000 .797

Time’Group
Pillai’s Trace .719 35.987 2.000 23 .000 .000 .719
Wilks’ Lambda .281 35.987 2.000 23 .000 .000 .719
Hotelling’s Trace 2.553 35.987 2.000 23 .000 .000 .719
Roy’s Largest Root 2.553 35.987 2.000 23 .000 .000 .719

 

178

Table 0.7. RMA Tests of Within-Subjects Effects for POI-K
(Undergraduate Students Only)

 

 

Source Type III Sum df Mean F Sig Partial Eta
of Squares Square Squared
Time
Sphericity Assumed 4079.053 2 2039.526 70.929 .000 .747
Greenhouse-Geisser 4079.053 1 .587 2569.806 70.929 .000 .747
Huynh-Feldt 4079.053 1 .752 2328.063 70.929 .000 .747
Lower-bound 4079.053 1 .000 4079.053 70.929 .000 .747
Time‘Group
Sphericity Assumed 2619.976 2 1309.988 45.558 .000 .655
Greenhouse-Geisser 2619.976 1 .587 1650.586 45 .558 .000 .655
Huynh-Feldt 2619.976 1.752 1495.315 45 .558 .000 .655
Lower-bound 2619.976 1 .000 2619.976 45 .558 .000 .655

 

Table 0.8. Linear Trend Table (Tests of Within—Subjects Contrasts) from Hypothesis 1

 

 

Source Time Type [11 Sum df Mean F Sig. Partial Eta
of Squares Square Squared
Time Linear 4360.418 1 4360.41 8 96.054 .000 .768
Quadratic 861 .398 l 861 .398 40.612 .000 .583
Time*Group Linear 3354.451 1 3354.451 73 .894 .000 .718
Quadratic 251 .550 l 251 .550 1 1.860 .002 .290
Error (Ti me) Linear 13 16.469 29 45 .395
Quadratic 615.090 29 21 .210

 

I79

Table 0.9. Group Pairwise Comparisons from Hypothesis 1

 

95% Confidence Interval for

 

Difference
(I) (I) Mean Std
Group Group Difference (I-J) Error Sig Lower Bound Upper Bound
B A -21.121* 2.724 .000 -26.703 -15.559
A B 21.131* 2.724 .000 15.559 26.703

 

Table 0.10. Time Pairwise Comparison from Hypothesis 1

 

(I) (J) Mean

95% CI for Difference

 

Time Time Difference (I-J) Std Error Sigl' Lower Bound Upper Bound
l 2 -14.850* 1.517 .000 -18.704 -10.996
3 -l6.781* 1.712 .000 -21.132 -12.431
2 1 14.850* 1.517 .000 10.996 18.704
-1.931 1.104 .273 -4.737 .875
3 1 16.781* 1.712 .000 12.431 21.132
2 1.931 1.104 .273 -.875 4.737

 

”r Adjustment for multiple comparisons: Bonferroni
*The mean difference is significant at the .05 level

180

Table 0.1 l . Group A POI-U Subscales Change Due to Intervention

 

 

Baseline Week 3 Week 6
Social Support 37.60 42.60** 45.27T
Relationship 36.40 38.53 40.07**
Sport Psychology 25.40 32.001L 37.931L
Attention 27 .47 2953* 30.13
Communication V 45.80 50.47‘r 53.131L
Motivation 26.67 33.13** 37.13?

 

*Indicates significant increase from baseline at 0.05 level
**Indicates significant increase from baseline at 0.01 level
Tlndicates significant increase with Bonferroni correction (0.004)

Table 0.12. Baseline and Follow-up POI-U Means & Standard Deviations (Hypothesis 2)

 

 

Group Mean SD N
Baseline POI-U Group B 198.8750 35.31171 16
Group A 199.3333 32.06838 15
Total 199.0968 33.21782 3 1
Week 3 POI-U Group B 210.8125 37.38131 16
Group A 226.2667 30.38671 15
Total 218.2903 34.51395 31
Week 6 POI-U Group B 214.0000 39.46306 16
Group A 243 .6667 25.19259 15
Total 228 .3548 36.08282 3 1

 

181

Table 0.13. Box M for Equality of Covariance Matrices from RMA for Hypothesis 2

 

 

Box’s M 6.860

F 1.014
dfl 6

df2 6016.462
Significance .414

 

Table 0.14. Levene’s Test of Equality of Error Variances from RMA for Hypothesis 2

 

 

 

 

 

F (If 1 df2 Significance
Baseline POI-K .335 1 29 .567
Week 3 POI—K 1.222 1 29 .278
Week 6 POI-K 2.963 1 29 .096
Table 0.15. Mauchly’s Test of Sphericity from RMA for Hypothesis 2
Epsilon
Within Mauchly's Approx Greenhouse- Huynh- Lower-
Subjects Effect W Chi-Square df Sig. Geisser Feldt bound
TIME 0.707 9.723 2 .008 .773 .837 .500

 

Table 0.16. Baseline and Follow-up POI—U Means and Standard Deviations
(Undergraduate Students Only)

 

 

Group Mean Standard Deviation N
Baseline POI-U Group B 202.4000 33.51077 15
Group A 187.6364 28.15767 1 1
Total 196.1538 31.64388 26
Week 3 POI-U Group B 215.1333 34.30924 15
Group A 217.3636 23.1 1395 l 1
Total 2 1 6 .0769 29.56609 26
Week 6 POI-U Group B 217.8000 37.69653 15
Group A 237.0000 17.57840 1 1
Total 225 .923 l 3 1 .82694 26

 

182

Table 0.17. RMA Multivariate Output for POI-U (Undergraduate Participants Only)

 

 

 

 

 

Effect Value F Hypothesis Error Sig Partial Eta
df df Squared
Time Pillai’s Trace .619 18.677 2.000 23 .000 .000 .619
Wilks’ Lambda .381 18.677 2.000 23 .000 .000 .619
Hotelling’s Trace 1.624 18.677 2.000 23 .000 .000 .619
Roy’s Largest Root 1.624 18.677 2.000 23 .000 .000 .619
Time’Group
Pillai’s Trace .343 5.999 2.000 23 .000 .008 .343
Wilks’ Lambda .657 5.999 2.000 23 .000 .008 .343
Hotelling’s Trace .522 5.999 2.000 23 .000 .008 .343
Roy’s Largest Root .522 5.999 2.000 23 .000 .008 .343
Table 0.18. RMA Tests of Within-Subjects Effects for POI-U
(Undergraduate Participants Only)
Source Type III Sum df Mean F Sig Partial Eta
of Squares Square Squared
Time
Sphericity Assumed 13738.697 2 6869.349 23.266 .000 .492
Greenhouse-Geisser 13738 .697 1 .63 1 8425 .656 23 .266 .000 .492
Huynh-Feldt 1. 3738.697 1.806 7608.029 23 .266 .000 .492
Lower-bound 13738.697 1.000 13738.697 23 .266 .000 .492
Time’Group
Sphericity Assumed 3660.236 2 1830.118 6.198 .004 .205
Greenhouse-Geisser 3660.236 1 .63 1 2244.746 6.198 .007 .205
Huynh-Feldt 3660.236 1.806 2026.915 6.198 .005 .205
Lower-bound 3660.236 1.000 3660.236 6.198 .020 .205

 

183

Table 0.19. Linear Trend (T ests of Within-Subjects Contrasts) from Hypothesis 2

 

 

 

 

 

 

 

 

Source Time Type III Sum df Mean F Sig. Partial Eta
of Squares Square Squared
Time Linear 13685.007 1 13685.007 32.510 .000 .529
Quadratic 431.329 1 431.329 1.873 .182 .061
Time‘Group Linear 3302.426 1 3302.426 7.845 .009 .213
Quadratic .792 1 .792 .003 .954 .000
Error (Time) Linear 12207 542 29 420.950
Quadratic 6678.122 29 230.280
Table 0.20. Group Pairwise Comparisons (Hypothesis 2)
95% CI for Difference
(I) (J) Mean Std
Group Group Difference (I-J) Error Sig Lower Bound Upper Bound
B A -15.193 10.922 0.175 -37.531 7.145
A B 15.193 10.922 0.175 -7.145 37.53]
Table 0.21. Time Pairwise Comparisons (Hypothesis 2)
95% CI for Difference
(I) (J) Mean
Time Time Difference (I-J) Std Error Sigl' Lower Bound Upper Bound
1 2 -19.435* 5.123 .002 -32.454 -6.417
3 -29.729* 5.214 .000 -42.978 -16.481
2 1 19.435* 5.123 .002 6.417 32.454
-10.294* 3.107 .007 -18.188 -2.400
3 1 29.729* 5.214 .000 16.417 42.978
2 10.294* 3.107 .007 2.400 18.188

 

T Adjustment for multiple comparisons: Bonferroni
*The mean difference is significant at the .05 level

184

Table 0.22. Group B POI-K Means & Standard Deviations (Hypothesis 3)

 

 

Group Mean SD ’ N
Baseline POI-K 14.4333 7.30427 15
Control Week 3 POI-K 17.7333 7.00986 15
Control Week 6 POI-K 15.8000 5.99047 15
Intervention Week 3 POI-K 34.1667 8.68016 15
Intervention Week 6 POI-K 37.6000 1 1.37541 15

 

Table 0.23. Mauchly’s Test of Sphericity from RMA for Hypothesis 3

 

 

Epsilon
Within Mauchly's Approx Greenhouse- Huynh- Lower-
Subjects Effect W Chi-Square df Sig. Geisser Feldt bound
TIME 0.307 14.670 9 .103 .686 .870 .250

 

Table 0.24. Linear Trend (Tests of Within-Subjects Contrasts) from Hypothesis 3

 

 

Source Time Type III Sum df Mean F Sig. Partial Eta
of Squares Square Squared
Time Linear 5909.482 1 5909.482 125.316 .000 .900
Quadratic 453 .201 1 453.201 21 .215 .000 .602
Error (Time) Linear 660.193 14 47.157
Quadratic 299.067 14 21 .362

 

185

Table 0.25. Time Pairwise Comparisons from Hypothesis 3

 

 

95% CI for Difference
(I) (J) Mean
Time Time Difference (I-J) Std Error SigT Lower Bound Upper Bound
1 2 -3.300 1.893 1.000 -9.597 2.997
3 - l .367 1.682 1.000 -6.961 4.228
4 -19.733* 2.113 .000 -26.760 -12.707
5 -23.167* 2.749 .000 -32.310 -14.023
2 1 3.300 1.893 1.000 -2.997 9.597
3 1.933 1.023 .798 -1.470 5.337
4 -16.433* 1.662 .000 -21.960 -10.907
5 -19.867* 1.742 .000 -25.660 -14.023
3 1 1.367 1.682 1.000 -4.228 6.961
2 -1.933 1.023 .798 -5.337 1.470
4 -18.367* 1.847 .000 -24.509 -12.225
5 -21.800* 2.178 .000 -29.044 -14.556
4 1 19.733* 2.113 .000 12.707 26.760
2 16.433* 1.662 .000 10.907 21.960
3 18.367* 1.847 .000 12.225 24.509
5 -3.433 2.166 1.000 -10.638 3.771
5 1 23.167* 2.749 .000 14.023 32.310
2 19.867* 1.742 .000 14.073 25.660
3 21.800* 2.178 .000 14.556 29.044
4 3.433 2.166 1.000 -3.771 10.638

 

T Adjustment for multiple comparisons: Bonferroni
*The mean difference is significant at the .05 level

186

Table 0.26. Group B POI-U Subscale Change Due to Intervention

 

 

Baseline Week 3 Week 6
Social Support 38.56 40.93 42.80**
Relationship 3656 39.53? 40.001
Sport Psychology 28.75 34.20 3607*
Attention 27.75 28.87 29.33
Communication 43.13 47 .73 * 47.67
Motivation 24.13 32.00T 33.60**

 

*lndicates significant increase from baseline at 0.05 level
“Indicates significant increase from baseline at 0.01 level
'llndicates significant increase with Bonferroni correction (0.004)

Table 0.27. Group B POI-U Means & Standard Deviations (Hypothesis 4)

 

 

Group Mean SD N
Baseline POI-U 198.2000 36.44409 15
Control Week 3 POI-U 210.8667 38.69268 15
Control Week 6 POI-U 213.6000 40.81456 15
Intervention Week 3 POI-U 223.2667 38.93487 15
Intervention Week 6 POI-U 229.4667 46.54470 15

 

Table 0.28. Mauchly’s Test of Sphericity from RMA for Hypothesis 4

 

 

Epsilon
Within Mauchly's Approx Greenhouse Huynh- Lower-
Subjects Effect W Chi-Sgare df Sig. -Geisser Feldt bound
TIME 0.1 13 27.064 9 .001 .509 .596 .250

 

187

Table 0.29. Linear Trend (Tests of Within-Subjects Contrasts) from Hypothesis 4

 

 

 

 

Source Time Type III Sum Mean F Partial Eta
of Squares Square Squared
Time Linear 8422507 8422507 13.001 .003 .482
Quadratic 38571 38.571 .203 .659 .014
Error (Time) Linear 9069.493 14 647.821
Quadratic 2660.286 14 190.020
Table 0.30. Time Pairwise Comparisons from Hypothesis 4
95% CI for Difference

(I) (J) Mean

 

Time Time Difference (I-J) Std Error Sig‘r Lower Bound Upper Bound

1 2 -12.667 8.046 1.000 -39.426 14.092
3 -15.400 7.250 .520 -39.513 8.713
4 -25.067 8.144 .082 -52.150 2.017
5 -31.267 9.485 .053 -62.809 .276

2 1 12.667 8.046 1.000 -14.092 39.426
3 -2.733 4.658 .520 -18.225 12.759
4 -12.400 4.611 .176 -27.736 2.936
5 -18.600 6.134 .090 -39.000 1.800

3 1 15.400 7.250 .520 -8.713 39.513
2 2.733 4.658 1.000 -12.759 18.225
4 -9.667 3.704 .206 -21.986 2.652
5 -15.867* 3.675 .007 -28.088 -3.646

4 1 25.067 8.144 .082 -2.017 52.150
2 12.400 4.611 .176 -2.936 27.736
3 9.667 3.704 .206 -2.652 21.986
5 -6.200 3.716 1.000 -18.560 6.160

5 1 31.267 9.485 .053 -.276 62.809
2 18.600 6.134 .090 -1.800 39.000
3 15.867* 3.675 .007 3.646 28.088
4 6.200 3.716 1.000 ~6.160 18.560

 

“(Adjustment for multiple comparisons: Bonferroni
*The mean difference is significant at the .05 level

188

Table 0.31. Group B POI-K and POI—U Means and Standard Deviations for

Control and Intervention Periods

 

 

Mean N SD Std Error Mean

Pair 1

Control Week 3 POI-K 18.2813 16 7.11798 1.77949

Intervention Week 3 POI-K 32.0313 16 1 1.97006 2.99251
Pair 2

Control Week 3 POI-U 210.8125 16 37.38131 9.34533

Intervention Week 3 POI-U 209.3125 16 67.30797 16.82699
Pair 3

Control Week 6 POI-K 15.8000 15 5.99047 1.54673

Intervention Week 6 POI-K 37.6000 15 11.37541 2.93712
Pair 4

Control Week 6 POI-U 213.6000 15 40.81456 10.53827

Intervention Week 6 POI-U 229.4667 15 46.54470 12.01779

Table 0.32. POI-K and POI—U Group Means & Standard Deviations (Hypothesis 9)

 

 

Group Mean SD N
Week 3 POI-K Group B 34.1667 8.68016 15
Group A 44.0667 10/45546 15
Week 3 POI-U Group B 223.267 38.93487 15
Group A 226.2667 30.38671 15
Week 6 POI—K Group B 37.6000 1 1.37541 15
Group A 49.8667 12.85977 15
Week 6 POI-U Group B 229.4667 46.54470 15
Group A 243.6667 25.19259 15

 

189

Table 0.33. POI-K and POI-U Group Means & Standard deviations for Hypothesis 9
(Undergraduate Participants Only)

 

 

Group Mean SD N
Week 3 POI-K Group B 33.6071 8.72260 14
Group A 42 .4545 10.29431 1 1
Week 3 POI-U Group B 226.9286 37.62868 14
Group A 217.3636 23.11395 1 1
Week 6 POI-K Group B 37.9286 1 1.73072 14
Group A 45.8636 1 1.81544 1 1
Week 6 POI-U Group B 233.2857 45.79793 14
Group A 237.0000 17.57840 1 1

 

Table 0.34. POI-K Paired Sample Statistics from Dependent t-tests for Groups A and B
Combined (Research Question 1)

 

 

Group Mean N SD

Pair 1 Baseline 16.6852 27 8.3322
Retention Week 7 33.6852 27 13.7009

Pair 2 Baseline 18.3667 15 8.4483
Retention Week 14 32.3333 15 12.5920

Pair 3 Week 6 44.0185 27 12.8665
Retention Week 7 33.6852 27 13.7009

Pair 4 Week 6 49.8667 15 12.8598
Retention Week 14 32.3333 15 12.5920

 

190

Table 0.35. POI-U Paired Sample Statistics from Dependent t-tests for Groups A and B
Combined (Research Question 1)

 

 

 

 

 

Group Mean N SD
Pair 1 Baseline 198.0357 28 34.4958
Retention Week 7 240.7500 28 32.5606
Pair 2 Baseline 199.3333 15 32.0684
Retention Week 14 236.9333 15 28.5369
Pair 3 Week 6 237.5714 28 34.4173
Retention Week 7 240.7500 28 32.5606
Pair 4 Week 6 243 .6667 15 25.1926
Retention Week 14 236.9333 15 28.5369
Table 0.36. Paired Sample Statistics from Dependent t—tests for Group A
Group Mean N SD
Pair 1 POI-U Baseline 199.3333 15 8.2800
POI-U Retention Week 7 241.80000 15 7.1941
Pair 2 POI-U Baseline 199.3333 15 8.2800
POI-U Retention Week 14 236.9333 15 7.3682
Pair 3 POI—U Week 6 243.6667 15 6.5047
POI-U Retention Week 7 , 241.8000 15 7.1941
Pair 4 POI-U Week 6 243.6667 15 6.5047
POI-U Retention Week 14 236.9333 15 7.3682
Pair 5 POI-K Baseline 18.5000 14 2.3388
POI-K Retention Week 7 41.8571 14 3.0551
Pair 6 POI-K Baseline 18.3667 15 2.1813
POI-K Retention Week 14 32.3333 15 3.2513
Pair 7 POI-K Week 6 48.8214 14 3.3853
POI-K Retention Week 7 41.8571 14 3.0551
Pair 8 POI-K Week 6 49.8667 15 3.3204
POI-K Retention Week 14 32.3333 15 3.2513

 

191

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Table 0.38. Paired Sample Statistics from Dependent t-tests for Group B

 

 

Group Mean N SD

Pair 1 POI-U Baseline 196.5385 13 10.6450
POI-U Retention Week 7 239.5385 13 10.6582

Pair 2 POI-U Week 6 230.5385 13 1 1.8477
Retention Week 7 2395385 13 10.6582

Pair 3 POI-K Baseline 14.7308 13 2.1391
POI-K retention Week 7 24.8846 13 2.8194

Pair 4 POI-K Week 6 38.8462 13 3.1498
POI-K Retention Week 7 24.8846 13 2.8194

 

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194

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