Luis Torres1, Fredrick A. Gardin2, Shala E, Davis3 and Colleen A. Shotwell4
1Department of Kinesiology, Montclair State University
2Department of Exercise Science, East Stroudsburg University
Correspondence concerning this article should be addressed to Luis Torres, Department of Kinesiology, Montclair State University, 1 Normal Ave, Montclair, NJ 07043. Email: [email protected].
Correlation Between Post-Injury Mental Health Symptoms and Rehabilitation Adherence in Collegiate Athletes
ABSTRACT
Purpose: To explore the correlation between post-injury mental health symptoms and rehabilitation adherence in collegiate athletes to gain knowledge that would improve rehabilitative recommendations. Methods: 19 National Collegiate Athletic Association athletes (M age: 20.58 ± 1.31) were assessed for depressive and anxious symptoms using the Hospital Anxiety and Depression Scale (HADS) after injury. Once they were cleared for full sports participation, they were administered the HADS again and the Rehabilitation Adherence Questionnaire (RAQ) to measure their perceptions of adherence to their rehabilitation programs. Results: A significant correlation was found between the two administrations of the HADS (R = .55, P = .03), but no significant correlations were found between RAQ scores and any of the HADS scores. Conclusions: Although the findings of this study did not establish a significant correlation between post-injury depression and anxiety symptoms and self-perceptions of rehabilitation adherence, strong evidence still exists to believe that poor mental health may be associated with poor rehabilitation adherence. Applications in Sport: Members of the collegiate athlete care team should be aware that the common underreporting of mental health symptoms in this population might make it difficult to establish the relationship between these symptoms and their recovery process after an injury. A holistic recovery approach should be considered in any injury recovery processes to allow collegiate athletes to heal both physically and psychologically.
Keywords: depression, anxiety, injury, recovery
Abbreviations: NCAA, National Collegiate Athletic Association; HADS, Hospital Anxiety and Depression Scale; RAQ, Rehabilitation Adherence Questionnaire
Introduction
Depression and anxiety remain as the leading mental health conditions among collegiate athletes, with as many as 30% and 50% of National Collegiate Athletic Association (NCAA) athletes reporting depression and anxiety, respectively, in a 2011 survey from the National College Health Association (NCAA, 2024). More recently, the American College of Sports Medicine (2024), in their 2021 statement on mental health challenges for athletes, found that the prevalence for depression and/or anxiety in this population ranges between 25% to 35% and only 10% of collegiate athletes with a known mental health condition seek help from a mental health professional. The reasons for this prevalence are multi-faceted given that collegiate athletes often maintain a strong athletic identity that is reluctant to ask for help and are faced with the societal perception of athletes always having to be immensely resilient during all hardships (Chang et al., 2020; Sarac et al., 2018; Tomalski et al., 2019; Wayment et al., 2017; Weigard et al., 2012; Wolanin et al., 2016). Collegiate athletes balance academic demands with their time-intensive and stress-inducing athletic demands while encountering issues relevant to sexuality, gender, hazing, bullying, sexual misconduct, body image, and sport transition (Greenleaf et al., 2009; Petrie et al., 2008; Putukian, 2016). The notion that athletes may be at a decreased risk for mental health conditions due to increased levels of exercise and other personality traits that can aid in athletic success has been shown to be a misconception (Chang et al., 2020).Furthermore, collegiate athletes are exposed to an abundance of additional unique risk factors for depression and anxiety when compared to non-athlete collegiate student counterparts (Demirel, 2016; Ghaedi et al., 2014; Hagiwara et al., 2017; Hanton et al., 2013; McGuire et al., 2017).
Unfortunately, sports injury is an often unavoidable element of collegiate athletics participation, with approximately 40% to 50% of collegiate athletes sustaining at least 1 injury requiring either medical attention or a participation restriction during their careers (Yang et al., 2014b). Injuries such as ligamentous sprains, muscular strains, skeletal fractures, joint dislocations, and concussions are relatively common (Yang et al., 2014a). Sports injuries further aggrandize the preexisting symptoms of depression and anxiety present in collegiate athletes due to the fact that a sports injury may serve as potentially one of the most physically and emotionally disturbing events that a collegiate athlete may experience during their career. Injured collegiate athletes experience enhanced risk factors of depression and anxiety such as fear of reinjury, trouble sleeping, poor concentration, emotional numbness, and injury conversation avoidance (Li et al., 2017; Padaki et al., 2018). They utilize the coping mechanisms of unrealistic wishful thinking, unhealthy venting of emotions, denial, and behavior disengagement (Wadey et al., 2014). Additively, social stressors and financial stressors have also been shown to substantially grow post-injury in collegiate athletes (Evans et al., 2012). Despite these complications, however, collegiate athletes are often still expected to adhere to sports rehabilitation exercise programs for a full recovery and timely return-to-sport.
Sports rehabilitation exercise programs are only effective for collegiate athletes when they are closely adhering to the instructions provided to them by their rehabilitative healthcare provider (Torres et al., 2023a). Poor rehabilitation adherence may prolong recovery, enhance reinjury risk, and reduce the likelihood of positive patient outcomes upon return-to-sport (Jack et al., 2010). The salient post-injury symptoms of depression and anxiety play a role in reducing rehabilitation adherence and hindering injury recovery in collegiate athletes (Baez et al., 2023; Torres et al., 2023b). However, given that as many as 98.3% of injured collegiate athletes have been reported to either overadhere and underadhere to their rehabilitation programs, more contemporary evidence is needed to further understand this extent of this role (Granquist et al., 2014). Despite the recent progress in collegiate athlete mental health screening that has been made, rehabilitative healthcare providers of injured collegiate athletes may not yet be collectively appropriately aware of the symptoms of depression and anxiety in rehabilitation. The purpose of this study was to explore the correlation between post-injury depression and anxiety and rehabilitation adherence in collegiate athletes in an effort to gain knowledge that would improve recommendations for sports rehabilitation programs.
Methods
Sampling
The sampling in this study was limited to two collegiate institutions of varying NCAA competition levels (NCAA Division II and NCAA Division III) within the Mid-Atlantic region of the United States. Demographic information on age, sex, NCAA competition level, race/ethnicity, academic eligibility level, type of sport, and type of musculoskeletal injury was collected from all participants. Participants were recruited by their athletic trainers after a sports injury had occurred and were included based on being 18 years of age or older and sustaining an acute musculoskeletal sports injury that required the inability to engage in full sports participation for at least four weeks. The purpose of this four week requirement was to ensure that the injuries sustained were significant enough to require a rehabilitation program for at least a month (Shin et al., 2010). Collegiate athletes were excluded if they had a concussion, respiratory disease, metabolic disease, cardiac disease, autonomic nervous system disease, or chronic injury of an unknown origin.
Instrumentation
Zigmond and Snaith (1983) designed the Hospital Anxiety and Depression Scale (HADS) as a 14-item questionnaire to measure the symptoms of depression and anxiety. The HADS consists of two subscales that are constructed of seven items for symptoms of depression (HADS-D) and seven items for symptoms of anxiety (HADS-A). Each item contains responses that are individually scored on a scale from 0 to 3 with higher scores indicating a higher level of symptom frequency (i.e., not at all, sometimes, occasionally very often, nearly all the time, etc.). The combined score of emotional distress (sum of HADS-A and HADS-D) ranges from 0 to 42 with scores of 11 or higher indicating a potential for a clinically significant mood disorder case. The total score of each participant places them into one of the following categories: non-case/normal (0 – 7), borderline case/borderline abnormal (8-10), case/abnormal (11 – 21+). Correlations ranging from .76 to .41 for the seven anxiety items (P < .01) and from .60 to .30 for the seven depression items (P < .02) have been associated with this instrument (Zigmond & Snaith, 1983). Similarly, calculated Spearman correlations between subscale scores and confirmed psychiatric ratings have shown that R = .70 for HADS-D and R = .74 for HADS-A (P < .001). The HADS has been routinely established as an instrument that performs well in assessing the symptom severity and caseness of depression and anxiety in both psychiatric and primary care patients and the general population (including collegiate athletes) (Bjelland et al., 2002).
RAQ
Fisher et al. (1988) designed the Rehabilitation Adherence Questionnaire (RAQ) as a 40-item questionnaire to measure rehabilitation adherence, while Shin et al. (2010) later redeveloped the RAQ into a 25-item questionnaire and validated it for injured athletes. The RAQ consists of six subscales: support from significant others (five items), pain tolerance (five items), scheduling (four items), self-motivation (five items), perceived exertion (three items), and environmental conditions (three items), and participants using the RAQ rate their level of agreement to each item using a four-point scale (i.e., 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The responses to each statement are then summed for a total adherence score that can range from 25 – 100. Higher total adherence scores indicate that participants perceive themselves successfully adhering to and completing their rehabilitation programs as prescribed by their rehabilitative healthcare provider. Moderate to high intra-class correlation coefficients for the each of the six subscales (support from significant others = .81, pain tolerance = .64, scheduling = .72, self-motivation = .78, perceived exertion = .67, and environmental conditions = .82; P < .01) have been found for this instrument, thus indicating a high level of test-retest reliability within the RAQ (Shin et al.).
Data Collection
A non-experimental repeated-measures prospective cohort study design was used in the completion of this study. Human subjects research approval was provided from the East Stroudsburg University Institutional Review Board (protocol #ESU-IRB-041-2021) in March of 2021, with the data collecting period for this study starting in June of 2021 and ending in February of 2022. After an in-season sports injury had occurred, collegiate athletes who met the appropriate inclusion criteria were approached by their athletic trainer for voluntary participation in this study through the provision of an electronic informed consent form on their first full day of starting their rehabilitation programs. The collegiate athletes were made aware that their involvement in this study would not have any effect on their status as a student-athlete at their respective institution. Once enrolled in the study, the participants were asked to complete the HADS to measure their current post-injury depression and anxiety symptoms. Participants were then monitored throughout the duration of their rehabilitation programs until they received clearance for full sports participation from either their team physician and/or athletic trainer (i.e., at return-to-play). On the day this clearance was attained, the HADS was administered again as well as the RAQ to measure their self-perceptions of their adherence to their rehabilitation programs. All questionnaires in this study were administered through Health Insurance Portability and Accountability Act (HIPAA) compliant Google Forms on either a password-protected tablet, smartphone, or computer desktop with all collected data being deidentified, kept confidential, and storedin a password-encrypted computer.
Data Analysis
The IBM SPSS 27.0 Statistical Package was used to analyze all collected data once the data collection period was complete. Descriptive statistics were reported and Pearson product-moment correlation tests with a significance level of P < .05 were conducted among HADS and RAQ scores to attempt to further identify the relationships between post-injury depression and anxiety and rehabilitation adherence in collegiate athletes. The following criteria were used to interpret R values: little to no relationship (.00–.25), fair relationship (.25–.50), moderate to good relationship (.50–.75), and good to excellent relationship (above .75) (Portney & Watkins, 2009).
Results
The 19 participants (M age: 20.58 ± 1.31; 17 males, 2 females) in this study were primarily NCAA Division II student-athletes (73.7%), White Caucasian (63.2%), academic seniors (42.1%), and football athletes (63.2%). The participants sustained various musculoskeletal conditions such as foot/ankle injuries (36.8%), knee injuries (21.1%), hip/thigh injuries (21.1%), and shoulder injuries (21.1%) with three participants not being cleared for a return to full sports participation at the conclusion of the data collection period. The cleared participants (n= 16) took 96.63 ± 31.90 days to recover from their sustained injuries before they were cleared for full sports participation. For the completion of the post-injury HADS (i.e., HADS 1 administration), the participants (n = 19) scored an 11.58 ± 5.26, while for the completion of the return-to-play HADS (i.e., HADS 2 administration), the participants (n = 16) scored a 9.63 ± 5.83. The participants (n= 15) rated their self-perception of rehabilitation adherence to be 57.20 ± 4.95 on a scale of 25 to 100 using the RAQ. A significant positive correlation was found between HADS 1 and HADS 2 scores (R = .55, P = .03), but no significant correlations were found between RAQ and HADS 1 scores (R = .52, P = .85) or RAQ and HADS 2 scores (R = .14, P = .63).
Discussion
The mean scores of both HADS 1 and HADS 2 falling above the asymptomatic normal HADS category indicates that depressive and anxious symptoms remain a substantial presence for collegiate athletes at post-injury and return-to-play states. Furthermore, although the findings of this study did not establish a significant correlation between post-injury depression and anxiety symptoms and self-perceptions of rehabilitation adherence, there is still strong existing evidence from previous researchers to believe that poor mental health may be associated with poor rehabilitation adherence. Holt et al. (2019) organized a literature review of 34 studies on the topic of adherence to exercise therapy interventions in children and adolescents with musculoskeletal conditions among 6 different databases. The selected studies represented 1,563 participants (35% male, 65% female, 2-19 years old), 11 musculoskeletal conditions, and multiple exercise interventions. Commonly identified barriers to rehabilitation adherence in this review included time constraints, physical environment (location), and previous negative exercise experiences. Holt et al. concluded that a diversity of barriers and facilitators to exercise therapy for musculoskeletal conditions exist and current strategies to boost adherence are not consistent with contemporarily identified barriers and facilitators. They clinically referenced that making exercise enjoyable, social, and convenient may be important to maximizing rehabilitation adherence to exercise therapy in young, injured athletes.
Jack et al. (2010) developed a systematic review of 22 articles reporting on 20 independent cohort studies using the ADMED, CINAHL, EMBASE, MEDLINE, PUBMED, PSYCINFO, SPORTDISCUS, Cochrane Central Register of Controlled Trials, and PEDro databases to understand the barriers to treatment adherence in physiotherapy outpatient clinics. These researchers identified high quality studies that maintained a focus on the exploration of rehabilitation adherence in patients with musculoskeletal conditions. They found that there was strong evidence to indicate that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support, greater number of perceived barriers to exercise, and increased pain levels during exercise. They also found that the research focused on the ability of health professionals and health organizations to address these barriers was comparatively limited. Holt et al. (2019) and Jack et al. would agree that symptoms of depression and anxiety may negatively influence rehabilitation adherence and that future study on the barriers to rehabilitation adherence is essential to the development of useful interventions by sports medicine professionals and other healthcare providers.
Brewer et al. (2013) studied the predictors of adherence to home rehabilitation exercises following ACL reconstruction in a study of 91 (58 males, 33 females) post-operative patients. These patients completed measures of athletic identity, neuroticism, optimism, and pessimism before ACL surgery and measures of daily pain, negative mood, stress, and home exercise completion for 42 days postoperatively. These researchers found that their participants reported high levels of adherence to the prescribed exercise regimen and that the participants completed fewer home exercises on days when they experience more stress or negative moods. They concluded that day-to-day variations in negative mood and stress may contribute to adherence to prescribed home exercises. This conclusion may be generalizable to athletic training settings in collegiate athletics, as past studies have supported the presence of poor rehabilitation adherence by student-athletes in these settings (Granquist et al, 2014; Fisher et al., 1988).
Evans et al. (2012) researched the stressors experienced by injured athletes during the 3 phases of their recovery from sports injury (onset, rehabilitation, return to play) and the differences in the stressors experienced by team-sport athletes as compared to individual-sport athletes with the use of semi structured interviews. The sample in this study consisted of 5 previously injured high-level rugby players and five previously injured high-level golfers. These researchers found that the athletes in their study experienced sport, medical/physical, and social and financial stressors; they also found that these same athletes reported several differences in the stressors experienced across the 3 phases of injury recovery and between team and individual-sport athletes. These researchers stressed that their findings have important implications for the design and implementation of interventions aimed at managing the potentially stressful sport injury experience and facilitating the return of injured athletes to competitive sport. This research supports the notion that certain psychosocial components of sports injury affect the ability of collegiate athletes to return to sports participation without any limitations.
Wadey et al. (2014) explored the relationship between re-injury anxiety and return-to-play outcomes in a cross-sectional research study of 335 collegiate athletes (M age = 23.5 ± 6.6) from varying NCAA competition levels. The athletes in this study completed the RIA-RE subscale of the Reinjury Anxiety Inventory (RIAI) as an assessment of reinjury anxiety and the Return to Sport After Serious Injury Questionnaire (RSSIQ) as an assessment of the perceptions of athletes on returning to sport. These researchers also assessed the presence of coping strategies in these athletes with the use of the Crocker and Graham MCOPE measure. They found a positive relationship between re-injury anxiety and heightened return concerns (R = .62, P < .01) and significant indirect effects for coping were found for wishful thinking, venting of emotions, denial, and behavioral disengagement. They suggested that future researchers should continue to examine the relationship between anxiety and return-to-play outcomes using diverse methodologies.
Conclusions
With the premise that poor mental health may be correlated to poor rehabilitation adherence, it is reasonable to suggest that rehabilitative healthcare providers should have an invested interest in utilizing effective psychosocial interventions within their programming when treating injured collegiate athletes. Additionally, they should re-evaluate their own mental health screening practices to ensure that they are screening for appropriate mental health symptoms at baseline, at post-injury, and at return-to-play, as this is now considered best practice (Baez & Jochimsen, 2023). Rehabilitative healthcare providers should also be keenly aware of the fact that underreporting and a proven reluctance to ask for help in this population may play a role in masking certain symptoms through the entire rehabilitative process. These same elements may have also played a role as to why a relationship was not established between post-injury depression and anxiety symptoms and self-perceptions of rehabilitation adherence in this study. Other study limitations, including a small, predominantly White and male sample, timing and scheduling issues in the athletic training facility, and a lack of standardization when it came to the rehabilitation programs prescribed by the athletic trainers, could also have impacted the results. Future researchers should seek to create similar studies with much larger, diverse sample sizes that explore correlations between the individual subscales of HADS-D and HADS-A and the self-perceptions of rehabilitation adherence of collegiate athletes.
Applications in Sport
Members of the collegiate athlete care team, such as coaches, athletic trainers, and other healthcare providers, should be aware that the common underreporting of mental health symptoms in this population might make it difficult to establish the relationship between these symptoms and their recovery process after an injury. A holistic recovery approach should be considered in any injury recovery processes to allow collegiate athletes to heal both physically and psychologically. Despite their inability to sometimes be vulnerable and transparent in reporting, collegiate athletes clearly struggle with their mental health and more research is needed to better understand how the more nuanced aspects of depressive, anxious, and disordered eating symptomatology affect them while they are recovering from a sports injury. The best collegiate athletic environments are those that permit collegiate athletes to report any and all mental health symptoms, concerns, and crises without any fear of consequences stemming from coaches and other relevant personnel.
References
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