Athletes’ Use of Mental Skills During Sport Injury Rehabilitation

Athletes’ Use of Mental Skills During Sport Injury Rehabilitation

Research across the world has shown that mental skills (ie, strategies used to trigger and sustain ideal performance)1 can be helpful to athletes in the process of achieving optimal athletic performance.2 More spe- cifically, mental skills such as imagery,3 goal setting,4

self-talk,5 and relaxation techniques6 have all been documented as useful in facilitating, maintaining, and improving athletic performance. In accordance with these findings, the integrated model of psychological response to sport injury and rehabilitation7 asserts that mental skills are beneficial during sport injury rehabilitation. This model posits that personal and situational factors combine to influence athletes’ cognitive appraisal of their injury situation and, depending on their assessment (ie, thoughts about being injured), they exhibit emotional (ie, feelings about being injured) and behavioral (ie, actions and reactions to being injured) responses, both of which may influence their subsequent cognitive appraisals. The same process (cognitions affecting emotions, and emo- tions affecting behaviors) can also occur in the opposite direction. According to the model, the use of mental skills is deemed important during the sport injury process in a number of ways: (1) as a mediating factor influencing injury occurrence, (2) as a personal factor influencing cognitive appraisals, and (3) as a behavioral response potentially influencing both the cognitive appraisals and emotional response to the injury situation.

Athletes’ Use of Mental Skills During Sport Injury Rehabilitation

Monna Arvinen-Barrow, Damien Clement, Jennifer J. Hamson-Utley, Rebecca A. Zakrajsek, Sae-Mi Lee, Cindra Kamphoff, Taru Lintunen, Brian Hemmings, and Scott B. Martin

Context: Existing theoretical frameworks and empirical research support the applicability and usefulness of integrating mental skills throughout sport injury rehabilitation. Objective: To determine what, if any, mental skills athletes use during injury rehabilitation, and by who these skills were taught. Cross-cultural differences were also examined. Design: Cross-sectional design. Setting: College athletes from 5 universities in the United States and a mixture of collegiate, professional, and recreational club athletes from the United Kingdom and Finland were recruited for this study. Participants: A total of 1283 athletes from the United States, United Kingdom, and Finland, who participated in diverse sports at varying competitive levels took part in this study. Main Outcome Measures: As part of a larger study on athletes’ expectations of injury rehabilitation, participants were asked a series of open-ended and closed-ended questions concerning their use of mental skills during injury rehabilita- tion. Results: Over half (64.0%) of the sample reported previous experience with athletic training, while 27.0% indicated that they used mental skills during injury rehabilitation. The top 3 mental skills reported were goal setting, positive self-talk/positive thoughts, and imagery. Of those athletes that used mental skills, 71.6% indicated that they felt mental skills helped them to rehabilitate faster. A greater proportion of athletes from the United States (33.4%) reported that they used mental skills during rehabilitation compared with athletes from the United Kingdom (23.4%) and Finland (20.3%). A small portion (27.6%) of the participants indicated that their sports medicine professional had taught them how to use mental skills; only 3% were taught mental skills by a sport psychologist. Conclusions: The low number of athletes who reported using mental skills during rehabilitation is discouraging, but not surprising given research findings that mental skills are underutilized by injured athletes in the 3 countries examined. More effort should be focused on educating and training athletes, coaches, and sports medicine professionals on the effectiveness of mental training in the injury rehabilitation context.

Keywords: injured athletes, psychological interventions, survey design, cross-cultural

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Existing empirical evidence suggests that the application of mental skills during rehabilitation sup- ports this model.8–11 Sports medicine professionals (SMPs), such as athletic trainers and physiotherapists, use a range of mental skills with athletes during reha- bilitation,9–13 and research indicates that goal setting is the most popular technique used by both athletic trainers and physiotherapists, regardless of the cultural context.9–13 Research conducted in the United States indicates that SMPs’ attitudes toward the effective- ness of mental skills vary, depending upon their level of formal training with cognitive skills application.14 Hamson-Utley et al found that athletic trainers held more positive attitudes toward the usefulness of mental skills than physiotherapists.14 Although studies dem- onstrate that adopting mental skills during rehabilita- tion is warranted and welcomed by the SMPs, there is limited research on athletes’ actual accounts of its use. Moreover, previous investigations on the performance context indicate varying cross-cultural differences.15,16 Thus, further investigation is required to determine if these cultural influences dictate the application of such skills in a sport injury rehabilitation context.

In addition to the sparse research available on the prevalence of athletes’ use of mental skills during reha- bilitation, there is limited information on which sports professionals are best positioned to assist athletes to use mental skills during sport injury rehabilitation. Ideally, injured athletes should have access to a sports medicine team that includes a credentialed sport psychology pro- fessional,17,18 however, most athletes and SMPs typically have limited access to sport psychology services.19,20 As a result, other professionals, such as athletic trainers and physiotherapists, are often implementing mental skills during rehabilitation. Whether SMPs or other allied health professionals are teaching mental skills to athletes during rehabilitation warrants further research.

To address these gaps in the literature, we attempted to preliminarily determine: (1) what, if any, mental skills athletes use during injury rehabilitation; (2) if there were any possible cross-cultural differences in athletes’ use of mental skills during injury rehabilitation; and (3) who teaches mental skills to athletes during rehabilitation.

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

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

Table 1 Participants’ Age Range and Sex by Country

Age, y

United States United Kingdom Finland Total Male Female Male Female Male Female Male Female

n % n % n % n % n % n % n % n % 12–17 1 0.2 0 0.0 2 0.9 0 0.0 48 33.3 16 14.8 51 6.4 16 3.5 18–21 319 71.7 221 88.0 90 42.7 55 53.4 26 18.1 43 39.8 435 54.4 319 69.0 22–25 113 25.4 28 11.2 23 10.9 7 6.8 33 22.9 29 26.9 169 21.2 64 13.9 26–35 11 2.5 2 0.8 22 10.4 15 14.6 32 22.2 18 16.7 65 8.1 35 7.6 36+ 0 0.0 0 0.0 74 35.1 26 25.2 5 3.5 2 1.9 79 9.9 28 6.1 Total 444 55.6 251 54.3 211 26.4 103 22.3 144 18.0 108 23.4 799 62.4 462 36.0

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As part of a larger study on athletes’ expectations of injury rehabilitation,21,22 participants were asked a series of questions regarding their use of mental skills during injury rehabilitation. These inquiries contained both open-ended and closed-ended questions. More specifi- cally, the first question participants were asked relative to their use of mental skills in injury rehabilitation was a closed-ended question: “Have you ever used mental skills as part of your sport rehabilitation?” Question 2, an open-ended question, allowed participants to list up to 3 mental skills they had used during their injury rehabilita- tion. Question 3, a closed-ended question, was: “Did the athletic trainer(s) teach you how to use the skills?” The fourth question, a follow-up to the previous question, was open-ended: “If no, who did?” The final question was closed-ended: “Do you believe that the use of mental skills helped you to rehabilitate faster?”

The survey items were modified for the UK and Finn- ish sample to take into account cultural differences. For the UK survey, the term, “athletic trainer,” was changed to “physiotherapist” to reflect the differences in professional titles used in these different cultural contexts. In Finland, the original questions were translated into Finnish follow- ing a commonly employed back-translation procedure23,24 used in cross-cultural research:

1. The original questions were translated from Eng- lish to Finnish by an independent sport psychology researcher who is fluent in both languages. At this stage, the term, “athletic trainer,” was also changed and translated to “physiotherapist” to reflect the differences in professional titles used in different cultural contexts.

2. The Finnish translated version was then translated back into English independent of the original ques- tions by a sport psychology professional who is fluent in both languages but was not involved in the initial translations.

3. The differences in the content and meanings between the back-translated and the original questions were then identified.

4. Due to the simplicity of the questions, no items displaying discrepancy in either content or meaning were identified.

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

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

Statistical Analyses

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

Results Of the 1283 participants, 346 (27.0%) indicated that they had applied mental skills during injury rehabilita- tion, whereas 880 (68.6%) stated that they had not used mental skills during rehabilitation (4.4% nonresponse). Among those who reported using mental skills, the top 4 mental skills used were (1) goal setting (162, or 46.8%), (2) positive self-talk/positive thoughts (115, or 33.2%), (3) imagery (110, or 31.8%), and (4) relaxation (84, or 24.3%). Table 2 displays the athletes’ use of specific mental skills by country. Of the 346 athletes who used mental skills, 249 (72.0%) indicated that the use of mental skills helped them to rehabilitate faster, whereas 48 (13.8%) felt that using mental skills did not facilitate the speed of their injury recovery (14.2% chose not to answer this question).

A significant difference (χ2 = 20.08, df = 2, P < .001) was obtained based on the athletes’ country (see Table 3). That is to say, a greater proportion of athletes from the United States (33.4%) reported that they used mental skills during rehabilitation compared with the proportion of athletes from the United Kingdom (23.4%) and Finland (20.3%). No significant difference (χ2 = 0.378, df = 2, P > .05) was found between the percentage of use of mental skills by males and females during injury rehabilitation.

Of the participants who reported using mental skills as part of their sport injury rehabilitation, 96 (27.7%) indicated that their SMPs (ie, athletic trainer, physiothera- pist or equivalent) had taught them how to apply mental

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skills. Other sources included a coach (52, or 15.0%), the athlete themselves (28, or 8.1%), the athlete’s family (26, or 7.5%), or a sport psychologist (10, or 2.9%). There was a 38.7% nonresponse rate.

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

additional studies9–12 indicate that when working with injured athletes, setting short-term goals appears to be the second-most used technique by SMPs overall (second to creating variability in rehabilitation exercises).

However, research remains unclear on the use, perceptions, and effectiveness of self-talk and imagery during injury rehabilitation. Hamson-Utley and col- leagues14 reported that among SMPs, use of self-talk and imagery was perceived as less effective than goal setting in sport injury rehabilitation. Nevertheless, other studies9–12 that explored the views and experiences of SMPs who use mental skills show that, along with setting goals, encouraging positive self-talk appears to be one of the most advocated mental skills by SMPs, whereas the use of imagery is among the 3 least-used mental skills that SMPs employ during sport injury rehabilita- tion. Estepp’s31 research on National Collegiate Athletic Association (NCAA) division I athletic trainers pro- vided further insight into the use of mental skills during rehabilitation, in that they reported using goal setting, communication, and time management more often than self-talk, relaxation, or imagery when working with injured athletes during rehabilitation.

Of the athletes in the current study who had reported using mental skills during rehabilitation, 72.0% believed that the use of such skills influenced the speed of their recovery and that the mental skills had a positive impact on their injury recovery. Research on the effects of mental skills in improving performance may influence athletes’ perceptions or beliefs that such skills will likely be beneficial during their injury rehabilitation. In addi- tion, research that highlights the mind–body connection suggests that patients who believe in and commit to their therapy perceive it as much more effective.32 Since only 27.0% reported that they used these tools during their rehabilitation, further understanding of why mental

Table 2 Specific Mental Skills Used During Rehabilitation

Mental skill

United States (n = 222)

United Kingdom (n = 74)

Finland (n = 50)

Total (N = 346)

n % n % n % n % Goal setting 115 51.8 24 32.4 23 46.0 162 46.8 Positive self-talk/positive thoughts 88 39.6 21 28.4 6 12.0 115 33.2 Imagery 70 31.5 22 29.7 18 36.0 110 31.8 Relaxation 57 25.7 6 8.1 21 42.0 84 24.3 Other 15 6.8 2 2.7 1 2.0 18 5.2

Table 3 Use of Mental Skills During Sport Injury Rehabilitation by Country (N = 1226)

Use or nonuse

United States (n = 664)

United Kingdom (n = 316)

Finland (n = 246)

n % n % n % Use mental skills during injury rehabilitation 222 33.4 74 23.4 50 20.3 Do not use mental skills during injury rehabilitation 442 66.6 242 76.6 196 79.4

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

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skills are underutilized during rehabilitation warrants further investigation.

A secondary purpose of the current study was to investigate whether possible cross-cultural differences existed in athletes’ use of mental skills during injury rehabilitation. Results indicated a significant difference in mental skill use, as US athletes (33.4%) used mental skills more within injury rehabilitation contexts compared with their UK (23.4%) and Finnish (20.3%) counterparts. It is likely that this difference may be attributed to (1) athletes’ receptiveness toward sport psychology, (2) pos- sible cultural differences that exist in sporting cultures among the countries represented in this analysis, and (3) athletes’ exposure to athletic training services in the United States.

Athletes’ exposure to sport psychology may vary from one country to another due to how the services are governed and structured, which is likely to influence the availability of licensed, certified, or registered sport psychology professionals. In the United States, 2 main professional organizations promote and govern sport psychology consultants (Association for Applied Sport Psychology [AASP]33 and the American Psychologi- cal Association, Division 4734), whereas in the United Kingdom, the sport psychology profession is primarily governed by the British Psychological Society35 and the Health and Care Professions Council,36 and also to an extent, by the British Association of Sport and Exercise Sciences.37 In both the United States and United King- dom, clear educational pathways to the sport psychology profession exist. Several universities in both countries offer specific degrees that lead to a career path in sport psychology. In Finland, on the other hand, the Finnish Sport Psychology Association38 represents the profes- sion and, only very recently, the Finnish Psychological Association39 explicitly began to govern sport psychology certification. Regarding Finnish universities, only 1 in the country specifically offers a master’s level degree in sport psychology. Given the differences noted above, and the lack of publicly accessible registers of sport psychologists from each country, it is impossible to speculate the avail- ability of sport psychology services to athletes within each country. However, based on the current available data, the number of AASP Certified Consultants avail- able to athletes in the United States is 331.33 None of the UK-based organizations provide explicit lists of sport and exercise psychologists, so therefore, no comparable data from the United Kingdom is obtainable. The Finnish Psychological Association cites the number of certified sport and exercise psychologists as 12.39 Despite the lack of verifiable data, it seems likely that there are cultural differences among these countries in terms of access to sport psychology services.

Another factor that may explain cultural differ- ences affecting the use of mental skills in rehabilitation is the athletes’ own attitudes toward sport psychology in general. Previous research that has investigated ath- letes’ attitudes toward the use of sport psychology has also highlighted clear cultural differences. For example,

in a study investigating athletes’ attitudes toward sport psychology consultants, it was found that overall, elite Irish athletes appeared to hold positive attitudes toward sport psychologists and were receptive in seeking sport psychology help.40 In a similar study with athletes from the United States, United Kingdom, and Germany, it was found that US-based athletes were more likely to view sport psychology in a negative light than their UK and German counterparts.41 Previous studies40–44 also indicate that differences in attitudes toward sport psychology may exist as a result of sex, sport type, and level of competi- tion. Thus, it is possible that cultural differences found in this study are the result of multiple factors, rather than just geographical location or national culture.

Another component that may play a role in explain- ing the cultural differences found in the current study is the way in which sports are structured in each country. The majority of the athletes from the United States who participated in this study were collegiate-level student- athletes. In the United States, 28.3% of the athletic departments across 120 universities currently offer sport psychology services to their athletes,45 and of those that were included in this study, the majority (4 schools out of 5) routinely offered sport psychology services to their athletes. Therefore, it is likely that the US athletes in the current study had potentially higher than average exposure to sport psychology services. In addition, all NCAA universities in the United States employ certified athletic trainers to work with their student-athletes.46 As part of their educational training, these certified athletic trainers are required to have competencies in psychoso- cial aspects of injuries and rehabilitation.47 As a result of these requirements for certification, athletic trainers often implement mental skills training with college athletes for preventing injuries and facilitating recovery.48 Con- versely, physiotherapists’ educational training does not explicitly require formal education or practice regarding the psychosocial aspect of injuries. However, not all certi- fied athletic trainers and physiotherapists working in the field today received training under the current educational competencies (since they may have received their educa- tion before the issuing of the new competency require- ments), and this may influence the use and perception of the effectiveness of mental skills in rehabilitation.17 Thus, to provide athletes with holistic care during the injury rehabilitation process, and to ensure both physical and psychological aspects of injuries are addressed as required, further professional relationships and referral networks between different professionals (particularly for those SMPs with limited sport psychology training and expertise) should be advocated and developed.

In the United Kingdom and Finland, the structure of competitive sports is more private or voluntary club- focused, and the hope of becoming an elite athlete is not linked to the university structure as it is in the United States. It is also common that sport psychology profes- sionals and physiotherapists work independently outside of a private or voluntary club. Although the majority of the UK and Finnish sample were mainly collegiate- or

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university-aged athletes, due to the structure of sports in these countries, it is likely that their access to a sport psychology professional, or a SMP with training in sport psychology,49 was more limited than the US sample. Therefore, it is possible that athletes from the United States are exposed to mental skills because of their close proximity to professionals who are formally trained in sport psychology.

Given the limited use of mental skills by profession- als despite their proven effectiveness in the sport injury rehabilitation context,26,28,50 it is important to understand which professionals use mental skills to help injured athletes. Hence, the third purpose of this study was to determine which professionals have been teaching mental skills to athletes during injury rehabilitation. Results revealed that nearly 28% of injured athletes in this study reported learning mental skills from SMPs; however, of those, the vast majority were US-based athletes. In addition, athletes reported learning mental skills from coaches (15.0%), themselves (ie, self-taught; 8.1%), and family members (7.5%) during their injury rehabilitation. Ranked last are sport psychologists (~3.0%), who played an additional role in teaching injured athletes mental skills during injury rehabilitation.

The above findings are not surprising. While many believe that sport psychologists are the best profession- als to introduce and thus educate athletes on applying mental skills during rehabilitation, it is known that very few SMPs have access to sport psychology profession- als during sport injury rehabilitation.9–12,51 Therefore, the role of addressing psychological aspects of injuries often falls on the SMPs’ shoulders.52,53 Moreover, SMPs regularly work with athletes, and as such are uniquely positioned to address both physical and psychological aspects of recovery.28 Until sport psychologists become a more common, yet distinct part of a sports team, SMPs will continue to be responsible for the holistic care of athletes, rehabilitating their mind and body.54 Current medical rehabilitation research highlights the influence of the mind over the body.55 Not only are SMPs very aware of the mental side of injury, but this has also been demonstrated by several theories as evidenced through several studies.9,10,14,52 Today, this research informs many evidence-based medical practices, including those with injured athletes.54

Consistent with previous literature, the current findings indicate that athletes underutilize mental skills during injury rehabilitation, however, those who do use these skills find them helpful. As such, it may be imperative to regularly advocate the use of mental skills to all athletes. In the United States, SMPs are the most commonly-used professionals for this purpose. Since it is commonplace for athletes, particularly those at the elite level, to use mental skills to enhance performance, the role of SMPs may not be so much to teach new mental performance skills, but to show athletes how to apply mental skills once they have been injured. In other words, it may be that one of the roles of SMPs in their pursuit to provide the best care

possible is to connect the dots for injured athletes, showing them how their performance-related mental skills can be applied to their rehabilitation from injury, which is often a foreign or challenging environment for most athletes.56

Similar to the performance enhancement context, skills like goal setting, positive self-talk, and imagery have been shown to be instrumental throughout the 3 phases of the injury recovery process.57 Research shows that SMPs are often confident in using goal setting and communication,52,58 and that their education likely has an influence on what skills they choose to employ. The professional preparation for most, if not all, of the allied health care professionals includes traditional education on writing patient notes, or SOAP (subjective, objective, assessment, and plan) notes, in which the P represents the plan for patient care. Hence, SMPs regularly use goal setting strategies in the delivery of their rehabilitation services and are likely comfortable teaching these skills to their patients. Some of these SMPs may have been formally trained to use imagery or self-talk, whereas others, particularly those representing the generations that graduated before the implementation of psycho- social educational competencies, are reluctant to use these skills with injured athletes due to conceptual misunderstandings related to how such psychosocial skills may work in practical settings.52 Given that there is a lack of research on how to best implement psycho- logical skills into rehabilitation,59 it is important for practitioners to ensure that they are advocating skills that (a) are within their own personal competencies, (b) athletes feel comfortable with, and (c) are meeting the needs of the athletes at a given phase of their rehabili- tation.57 The literature also suggests that practitioners should identify their athletes’ psychological needs (ie, stress and anxiety) and then select 1 or 2 mental skills or techniques based on their ability, comfort, and prior success.60

Despite a number of meaningful findings, the study was not without its limitations. More specifically, the results of the current study should not be generalized to all athletes in the United States, United Kingdom, and Finland, or with athletes at other competitive levels. First, the differences in the structure, level of sports, and the varying age groups who participate in sports within the 3 countries could have impacted the results obtained in this study. Second, the different environments (eg, before or after practice or in a classroom setting) in which the data were collected, in addition to the differ- ent methods used (online versus in person), could have influenced the quality of data collected, thereby also influencing the results obtained. Third, the differential access to athletic trainers/physiotherapists and the survey’s failure to inquire about participants’ access to these SMPs could possibly have influenced the findings in the current study. Fourth, the large nonresponse rate may potentially indicate a lack of interest in reporting the use of mental skills or potential nonuse. Finally, a lack of knowledge and exposure to sport psychology

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and mental skills could have influenced participants’ responses with regard to their use of mental skills in the injury rehabilitation context.

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

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

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