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A Cognitive Behavioral Intervention for College Athletes With Injuries

Article in Sport Psychologist · June 2020

DOI: 10.1123/tsp.2019-0112

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The Sport Psychologist, (Ahead of Print)
https://doi.org/10.1123/tsp.2019-0112
© 2020 Human Kinetics, Inc. APPLIED RESEARCH

A Cognitive Behavioral Intervention

for College Athletes With Injuries
Leslie W. Podlog John Heil
University of Utah Psychological Health Roanoke

Ryan D. Burns, Sean Bergeson, Tom Iriye, Brad Fawver, and A. Mark Williams
University of Utah

The authors used a quasi-experimental design to examine the efficacy of a cognitive-behavioral-therapy (CBT) intervention for
enhancing psychological well-being (positive and negative affect, vitality, self-esteem), rehabilitation adherence, and clinical
rehabilitation outcomes (pain, physical function) in 16 NCAA (National Collegiate Athletics Association) Division I athletes
experiencing a range of severe injuries. ANCOVAs, with adjusted baseline scores, revealed significant differences between the
experimental and control groups for positive affect at rehabilitation midpoint (T2; adjusted mean difference (AMD) = 0.41,
p = .04, η2 = .34) and return to play (T3; AMD = 0.67, p < .001, η2 = .70), negative affect at T3 (AMD = −0.81, p = .01, η2 = .47),
and vitality at T2 (AMD = 0.99, p = .01, η2 = .48) and T3 (AMD = 1.08, p = .02, η2 = .33). Given decrements in emotional
functioning after injury, the data support the use of CBT-based interventions for facilitating the emotional well-being of athletes
with severe injuries.

Keywords: athlete well-being, injury education, quasi-experimental design, vitality

The negative influence of sport injury on an athlete’s future
performance, as well as mental health and psychosocial well-being,
is well documented (Clement, Arvinen-Barrow, & Fetty, 2015;
Leddy, Lambert, & Ogles, 1994; Podlog & Eklund, 2006;
Putukian, 2016; Tracey, 2003). An examination of the literature
on the psychology of sport injury suggests that athletes with injuries
experience an array of concerns in the immediate-postinjury after-
math, during rehabilitation, and on their return to sport after injury
recovery. Prominent problems after injury occurrence include chal-
lenges with pain management, heightened negative affect, and
difficulties accepting one’s new incapacitations (Tracey, 2003).
During the rehabilitation phase other psychological challenges
commonly emerge, such as a loss of confidence in one’s physical
capabilities, feelings of social isolation, loss of athletic identity,
and inadequate social support (Clement & Shannon, 2011;
Ruddock-Hudson, O’Halloran, & Murphy, 2012; Tracey, 2003).
Finally, as an athlete’s return to sport approaches, excitement over
resumption of competitive activities may be dampened by reinjury
anxieties, worries about regaining previous competitive levels, and
trepidation about the impact of injury on skill execution (Podlog &
Dionigi, 2010; Podlog & Eklund, 2006). Moreover, returning
athletes might also worry about meeting internal and external
performance expectations, self-presentational concerns about ap-
pearing athletically incompetent, and doubts over their level of
physical fitness (Evans, Hardy, & Fleming, 2000; Podlog &
Eklund, 2006; Walker, Thatcher, & Lavallee, 2010).
Podlog, Burns, Bergeson, and Williams are with the Dept. of Health, Kinesiology,
and Recreation; Iriye, the Athletics Dept.; and Fawver, the Div. of Physical
Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA. Heil
is with Psychological Health Roanoke, Roanoke, VA, USA. Podlog (les.podlog@
utah.edu) is corresponding author.
Given the psychological challenges associated with injury
rehabilitation and return to sport, researchers and practitioners
have sought to enhance athletes’ coping skills through implementa-
tion of various psychological interventions. In particular, psycho-
logical strategies such as goal setting, imagery, relaxation, and
expressing gratitude have all been shown to positively affect the
rehabilitation of athletes with injuries (Cupal & Brewer; 2001; Evans
& Hardy, 2002; Naoi & Ostrow, 2008; Salim & Wadey, 2019;
Theodorakis, Beneca, Malliou, & Goudas, 1997; Theodorakis,
Malliou, Papaioannou, Beneca, & Filactakidou, 1996). However,
there remains a dearth of rigorous methodological designs in this
area of research (Cupal, 1998; Schwab Reese, Pittsinger, & Yang,
2012). In highlighting this paucity, Schwab Reese et al. (2012) found
only six published studies examining the efficacy of psychological
interventions on sport-injury-rehabilitation outcomes. Two studies
used randomized control trials (Cupal & Brewer, 2001; Evans &
Hardy, 2002), two used “before and after study designs” (Johnson,
2000; Mankad & Gordon, 2010), and two employed case-study
approaches (Mahoney & Hanrahan, 2011; Rock & Jones, 2002).
Since the publication of Schwab Reese et al.’s review, few additional
well-designed intervention studies have been conducted (e.g.,
Maddison et al., 2012; Salim & Wadey, 2019). Furthermore, re-
searchers have typically ignored the relationships between interven-
tion skills and adherence behaviors or clinical rehabilitation outcomes,
namely, pain levels and perceived functional ability (Walker &
Arvinen-Barrow, 2013), shortcomings we sought to address in the
current investigation. Finally, to our knowledge, no intervention
studies to date have specifically focused on college athlete popula-
tions, a cohort facing unique challenges given the need to maintain
academic standing in the face of competitive and scholarship demands
(Wilson & Pritchard, 2005).
Despite calls for well-designed psychological interventions in
the area of injury rehabilitation (Cupal, 1998), few researchers have,
1
2 Podlog et al.
to date, heeded such recommendations (for some exceptions see
Cupal & Brewer, 2001; Evans & Hardy, 2002; Maddison et al.,
2012; Salim & Wadey, 2019). As highlighted herein, the present
study represented an effort to add to the relatively limited body of
intervention research, in particular with injured NCAA (National
Collegiate Athletics Association) Division I athletes. We also sought
to build on existing research by examining the influence of a
psychological intervention on a critical recovery behavior—
rehabilitation adherence (Evans & Hardy, 2002)—as well as ad-
dressing key indicators of clinical/functional outcomes.
The development of our intervention was informed by tenets
of cognitive-behavioral therapy (CBT), a widely used and
exhaustively investigated intervention method that has demon-
strated clinical efficacy in helping individuals manage dysfunc-
tional emotions, maladaptive behaviors, and disruptive cognitive
processes (Zhang et al., 2019). Focusing on how individuals
appraise or interpret events is a central component of CBT-based
interventions (McGinn & Sanderson, 2001). In CBT, personal
evaluations, meanings, and philosophies about the world are
critical for understanding how people react to events in their
lives, whether an event be a sport injury, a perceived negative
interaction with a colleague, or a failure to achieve a personal goal
(McGinn & Sanderson, 2001). From a CBT standpoint, an injured
athlete’s maladaptive thoughts and concerns are likely to lead to
unpleasant emotions, which in turn negatively influence motivation
and engagement in important rehabilitation behaviors such as adher-
ence to the prescribed rehabilitation program. The central premise of
CBT is that altering maladaptive thoughts leads to a change in
psychological affect (emotions) and in subsequent behavior
(McGinn & Sanderson, 2001; Zhang et al., 2019). Adherence
behaviors such as showing up to rehabilitation sessions, complying
with activity restrictions, managing pain, and putting appropriate
effort into rehabilitation exercises have all been shown to predict
enhanced clinical and return-to-sport outcomes (Alzate Saez de
Heredia, Ramirez, & Lazaro; 2004; Brewer et al., 2004; Evans &
Hardy, 2002; Evans et al., 2000; Pizzari, Taylor, McBurney, &
Feller, 2005).
Given the limitations associated with past psychological inter-
ventions conducted with injured athletes, the purpose of the present
study was to examine the efficacy of a CBT intervention for
enhancing the well-being, rehabilitation adherence, and clinical
outcomes of athletes with injuries. Guided by CBT tenets, we chose
to examine cognitive and affective indicators of well-being shown
to be disrupted in the aftermath of injury (Clement et al., 2015;
Leddy et al., 1994; Podlog, Lochbaum, & Stevens, 2010) and to
examine behavioral (adherence) and clinical outcomes (pain and
functional ability) recognized as fundamental to the success of
rehabilitation (Alzate Saez de Heredia et al., 2004; Brewer et al.,
2004; Evans & Hardy, 2002; Pizzari et al., 2005). Given extensive
research demonstrating the prevalence of negatively valanced
emotions after injury (Smith et al., 1993; Tracey, 2003; Walker;
Thatcher, & Lavallee, 2007), as well as evidence highlighting the
debilitating impact of injury on athletes’ energy levels (vitality) and
self-esteem (Podlog, Lochbaum, & Stevens, 2010; Tracey, 2003;
Wasley & Lox, 1998), it seemed reasonable to examine the impact
of our CBT intervention on these salient cognitive and affective
variables of well-being. Furthermore, as indicated, although
numerous studies have demonstrated positive links between adher-
ence and rehabilitation outcomes (Alzate Saez de Heredia et al.,
2004; Brewer et al., 2004; Evans & Hardy, 2002; Pizzari et al.,
2005), surprisingly few scholars have examined the implications
of psychological interventions on critical behaviors such as
(Ahead of Print)
rehabilitation adherence (Schwab Reese et al., 2012), a shortcom-
ing we sought to rectify in the current investigation. Finally, given
empirical evidence suggesting positive links between rehabilitation
adherence and enhanced clinical and functional outcomes, we
hypothesized that our intervention would not only augment adher-
ence behaviors but also hold positive implications for injured
athletes’ functional capabilities.
Based on previous research demonstrating improvements in
athlete well-being and functional abilities as rehabilitation pro-
gresses (Evans et al., 2000; Clement et al., 2015; Tracey, 2003), we
hypothesized that both control and experimental groups would
demonstrate changes over time in our dependent outcomes of
interest. Furthermore, we hypothesized that athletes in the experi-
mental condition would show greater well-being (enhanced affect,
vitality, self-esteem) and rehabilitation adherence and improved
clinical outcomes (reduced pain and increased perceived functional
ability) than athletes in the control group receiving only a program
of physical rehabilitation. Based on the central tenets of CBT,
experimental-group athletes were expected to demonstrate enhanced
self-regulation skills (relative to controls), which would in turn
promote adaptive rehabilitation behaviors and outcomes.
Methods
Power Analysis
A power analysis was conducted using ANOVA procedures with
an expected large effect (f = 0.40), a factorial design within-
between interaction for each outcome variable, and a correlation
between repeated measures of r = .5. The expected large effect
size was based on previous intervention research showing similar
effects (Cupal & Brewer, 2001; Maddison et al., 2012). For
example, Cupal and Brewer (2001) found experimental evidence
supporting the effects of relaxation and guided imagery on reinjury
anxiety and pain. Specifically, variance effect-size calculations
revealed that the treatment accounted for approximately 62% of
the variance in reduction of reinjury anxiety (η2 = .62) and approx-
imately 76% of the variance in the overall reduction of pain
(η2 = .76). Using the aforementioned parameters, 14 participants
would need to be recruited for the current study to achieve 80%
statistical power.
Participants
Sixteen athletes with injuries were recruited from a large uni-
versity in the southwestern United States with the assistance of
the associate director of athletic training. To be eligible for
participation, athletes were required to be 18 years of age or
older, have incurred an injury requiring a minimum 4-week
absence from training or competitive performance (i.e., a period
of competitive absence likely to result in well-being decrements;
Podlog & Eklund, 2006), and not have entered the sports-
medicine clinic more than 1 week prior to their involvement
in the study. This final criterion helped ensure that all partici-
pants were at the same point in their rehabilitation schedule and
that athletes in the experimental group had the opportunity
to cultivate and use CBT skills throughout their rehabilitation.
Any participants not meeting all three eligibility criteria were
excluded. These criteria resulted in a sample of 12 female and
4 male NCAA Division I athletes (6 female and 2 male in
experimental and control groups, respectively) with an age
of 19.94 ± 1.69 years (M ± SD; mean age = 20.13 in the

experimental group and 19.75 in the control group). All parti-
cipants had experienced a serious injury that entailed absence
from sport training/competition for 13.31 ± 12.34 weeks. The
average injury time loss for the experimental group was
15.13 weeks, and 11.5 weeks for the control group, t(14) =
0.42, p = .67, suggesting that athletes in both groups were
missing sport-specific training and competition for relatively
prolonged periods of time (i.e., approximately 3 months), with
no statistically significant differences between groups. Injury
types included torn anterior cruciate ligament (n = 6), stress
fracture/reaction (n = 3), sprain (n = 2), tendonitis (n = 1), torn
knee cartilage (n = 1), broken fibula and tibia (n = 1), torn disc
and arthritis in lumbar spine (n = 1), and rotator cuff overuse
(n = 1). Participants competed in a range of sports, specifically,
track and field (n = 5), football (n = 3), basketball (n = 1), soccer
(n = 3), volleyball (n = 1), diving (n = 1), gymnastics (n = 1), and
tennis (n = 1). Given the serious nature of the injuries across the
experimental and control groups, none of the participants were
engaged in sport-specific training—be it coach-dictated or per-
sonal training. All but three participants had experienced at least
one previous severe injury (M = 1.93) requiring a 4-week com-
petitive absence. Ethical approval was obtained from the lead
institution before data collection, and all athletes gave their
written consent before participating.
Design
Our aim in the current study was to examine the impact of our
CBT-grounded intervention on NCAA Division I varsity athletes
with a current injury. We adopted a quasi-experimental design,
given that participants were rehabilitating in a single facility
where there was open and regular communication between
athletes. As such, we wanted to avoid contamination effects
whereby athletes in the experimental group discussed contents of
the intervention (i.e., skills they learned and/or workbook ma-
terials they received) with those in the control group. Conse-
quently, we used a quasi-experimental, repeated-measures
design in which the first eight athletes meeting the eligibility
criteria were assigned to the experimental/intervention (CBT)
group and the second cohort of eight athletes was assigned to the
control group. Athletes in the control group completed their
regularly scheduled program of physical rehabilitation as set out
by their treating athletic trainer. The nature and content of the
rehabilitation sessions varied as a function of the athletes’ injury
type. Athletes in the control group did not receive any of the CBT
intervention materials or training sessions described herein. We
employed a single-blind design in which injured participants
were unaware of the specific aims of the study or the group to
which they were assigned. All participants were informed that
they were being asked to partake in a research study examining
the well-being of athletes with injury and their rehabilitation
and recovery outcomes. Athletic trainers were not blind to
the purposes of the study or which group participants were
allocated to, for the following reasons: We required approval
from the associate director of athletic training—that is, one of
the treating athletic trainers in the study—to conduct the inves-
tigation; we relied on treating athletic trainers to facilitate
participant recruitment, so they were aware of participants’
group allocation; and athletic trainers were involved in the
intervention itself, specifically in terms of the “question and
answer” session involving the injury education guideline dis-
cussed following.
(Ahead of Print)
Cognitive-Behavioral Injury Intervention 3
CBT Intervention
The experimental group was trained in four CBT skills over four
consecutive weeks. Training in the CBT skills involved participa-
tion in four separate 1-hr sessions (i.e., a total of 4 hr), involving
one-to-one meetings between the athlete with an injury and a
member of the research team. In addition to the four individual
meetings, athletes partaking in the CBT intervention completed a
number of homework assignments—described in greater detail
following—that collectively took approximately 2.5–3 hr to com-
plete over the 4-week intervention. In total, athletes in the experi-
mental condition engaged in 6.5–7 hr of training over and above
their physical rehabilitation. To facilitate standardization of psy-
chological-skills content and delivery, a CBT intervention work-
book was developed. The member of the research team who
delivered the intervention had graduate training in sport psychol-
ogy, a detailed knowledge of the workbook content, and experience
working as a student-athlete academic mentor. Intervention skills
included injury education (Skill 1), attentional focus and distraction
control (Skill 2), managing emotions (Skill 3), and pain manage-
ment (Skill 4). Consistent with CBT principles, Skills 1 and 2 were
designed to alter maladaptive thinking (i.e., cognitive appraisals
related to the injury), while Skills 3 and 4 were intended to address
the affective and behavioral component of CBT. A copy of
intervention materials is available from the first author on request.
During the initial session, the intervention provider met indi-
vidually with the injured athlete after referral from the treating
athletic trainer. The purpose of the initial session was fivefold: to
build initial rapport, to ask the athlete about the nature of the injury,
to introduce the four skills included in the CBT intervention, to give
the athlete an initial self-assessment exercise, and to discuss an
injury education guideline. The self-assessment asked the athlete to
“rate your perceived knowledge or ability on each of the four
skills.” A definition of each skill was provided followed by a rating
scale of 0 (very poor) to 10 (excellent). The athlete received a score
out of a possible 40, with higher scores indicating greater knowl-
edge or ability on the CBT intervention skills. The overall and
individual item scores gave the intervention provider information
on the injured athlete and helped initiate a conversation regarding
why the athlete gave him- or herself a particular score on a specific
skill. Finally, in Session 1, the provider and the athlete discussed
the injury education guideline. The guideline was designed to
enhance Skill 1, that is, to cultivate the athlete’s knowledge of
the rehabilitation process, to develop his or her sense of personal
investment in the recovery process, and to facilitate adherence to
treatment tasks. Example content areas included basic anatomy of
the injured area, active/passive rehabilitation methods, rationales
for limits on physical activity during the acute injury phase, and the
notion of rehabilitation as an active collaborative learning process.
After reviewing the education guideline, the intervention provider
asked the athlete to schedule an appointment with his or her athletic
trainer. The guideline served as a heuristic to facilitate a question-
and-answer session between the athlete and the treating athletic
trainer. The guideline was intended to identify specific or targeted
points that might not emerge as part of the natural consultation or
treatment process. During the meeting, the athlete and athletic
trainer worked collaboratively to identify, discuss, and take notes
on bullet points listed in the education guidelines that were
germane to the athlete’s injury. Given the variability of injury
types and severity, athletic trainers necessarily provided idiosyn-
cratic responses to the injury education items (see example items
listed earlier). That said, there was likely some consistency in the
4 Podlog et al.
types of information conveyed to athletes experiencing similar
injuries and recovery timelines, for instance, among the partici-
pants undertaking rehabilitation for a torn anterior cruciate liga-
ment or a stress fracture. To solidify retention of key take-home
points from the meeting with the athletic trainer, athletes in the
experimental group discussed take-home points with the CBT
intervention provider.
In Session 2 (1-hr individual meeting), the intervention pro-
vider asked the athlete to discuss key points from the question-and-
answer meeting with the athletic trainer. This discussion was
followed by engagement in three different exercises designed to
enhance Skill 2, that is, to help the athlete enhance attentional focus
and manage distracting thoughts (Skill 2). In particular, the ex-
ercises helped the athlete problem solve by converting his or her
worries into productive action (Exercise 1), manage expectations
(Exercise 2), and shift from negative to positive thoughts (thought
stopping; Exercise 3). In Exercise 1, the intervention provider
discussed the idea that worry was thinking that tended to be cyclical
in nature, consumed energy and created anxiety, and generally
accomplished no useful coping purpose. After this discussion,
athletes were asked to complete a table in which they made a
list of concerns, devised solutions to specific concerns, and articu-
lated pros and cons associated with each solution. The intervention
provider suggested to the athlete that he or she work to adopt
solutions with the greatest number of pros and the least number of
cons. Exercise 2 (managing expectations) involved a discussion
about the potentially facilitative and/or debilitative role of expecta-
tions, followed by completion of a table in which athletes listed
injury-related expectations, the source of the expectation (internal
vs. external), and whether they felt the expectation “weighed them
down or lifted them up.” Based on the response to the latter
question, athletes were instructed to either “keep the expectation”
or to “get rid of it.” Finally, Exercise 3 (thought stopping) helped
the athletes redirect negative cognitions to more facilitative, action-
oriented thoughts that might be instrumental in addressing injury-
related challenges. In particular, the athletes completed a table in
which they identified specific negative thoughts, invoked a key
word/image/feeling (e.g., “stop,” “enough,” a rubber band snap-
ping against one’s wrist), and wrote down a replacement thought or
action to help them redirect their attentional focus.
In Session 3 (1-hr individual meeting), experimental-group
athletes participated in two prescribed intervention tasks. These
included a guided written emotional-disclosure exercise (Mankad,
Gordon, & Wallman, 2009) and an audio-guided relaxation CD
(Heil, 1993), both of which were designed to facilitate the injured
athletes’ emotional adjustment (Skill 3). With regard to the emo-
tional-disclosure exercise, each athlete was given a list of questions
intended to help him or her become more self-aware of any injury-
related thoughts and emotions. The questions were not intended to
be exhaustive but, rather, to help the athletes consider potentially
relevant emotional aspects of their injury. Example questions
included “What has been most difficult for you about your injury?”
“What are the things you miss the most about your sport?”
“Describe any impact of your injury on your energy levels.”
“Of all your emotions about your injury, which have been most
difficult and why?” and “In what ways has your social life changed
or do people treat you differently?” After completion of the written
emotional-disclosure exercise, athletes were given the opportunity
to discuss any comments they had written with the intervention
provider. The second half of Session 3 involved athletes listening to
an audio-guided mind–body relaxation CD. The relaxation CD was
designed to help the athletes modulate the intensity of negatively
(Ahead of Print)
valanced emotions and to promote muscle-to-mind relaxation. The
15-min script started by having the athletes turn their attention to
their breath, simply noticing the way they were breathing (fast/
slow, shallow/deep, smooth and regular). They were encouraged to
breath in a manner that is “slow, deep, and regular.” This compo-
nent was followed by a muscle relaxation, involving a count from 1
to 10, with each number associated with a particular area of the
body. Each athlete in the experimental condition was given the CD
and asked to complete the relaxation homework exercise on two
occasions before the fourth and final session the following week.
Session 4 (1-hr individual meeting) focused on pain manage-
ment (Skill 4). The intervention provider took the athlete through a
scripted visualization session (30–45 min) designed to help meet
the challenge of severe and persistent pain (Heil, 1993). The
visualization session invoked images (e.g., eye of storm) and
sensations (heat and cold) that enabled athletes to associate to
their pain and help them work with calm intensity within their pain
limits. The idea of associating with one’s pain—as opposed to
dissociating or blocking out one’s pain—was based on the paradox
of acceptance and surrender as a way of gaining power and control
over the pain (Heil, 1993). As with the other skills and exercises,
the intervention provider delivered the pain-visualization script to
experimental-group athletes on an individual basis. Prior to the
pain-management visualization exercise, the athlete listened to
the mind–body relaxation CD (15 min) described previously. At
the completion of Session 4, as a homework assignment, the
intervention provider asked the athlete to go through the pain-
management visualization on two occasions during the following
week. The athlete was also encouraged to use the visualization, as
or when needed, throughout his or her rehabilitation.
Measures
We collected relevant demographic information including age,
sport type, gender, injury type, severity (expected time loss
from competition), date of injury, and the number of severe injuries
previously incurred (defined as 4 weeks or more out of training and
competition) from participants at the time of their first question-
naire completion, that is, within their first week of rehabilitation.
Three indicators of well-being relevant to athletes with an injury
included the 20-item Positive and Negative Affect Schedule
(PANAS; Watson, Clark, & Tellegen, 1988), the 7-item Subjective
Vitality Scale (Ryan & Frederick, 1997), and the 10-item Self-
Esteem Scale (Rosenberg, 1965).
PANAS. The PANAS contained 10 items measuring positive
affect (e.g., excited, enthusiastic, determined; α = .82) and 10 items
measuring negative affect (e.g., distressed, upset, irritable; α = .85;
Watson et al., 1988). Responses to the statement stem “At present,
I feel . . .” were recorded on a Likert-type scale from 1 (strongly
disagree) to 5 (strongly agree). Subscale items were averaged to
form positive-affect and negative-affect scores. Researchers have
observed the PANAS to demonstrate factorial validity, as well as
acceptable Cronbach’s alphas and test–retest reliabilities across
different temporal instructions (Crawford & Henry, 2004; Watson
et al., 1988). The scale has been used in previous sport-injury
research (Podlog, Lochbaum, & Stevens, 2010; Wadey, Podlog,
Galli, & Mellalieu, 2016).
Subjective Vitality Scale. Six items from the Subjective Vitality
Scale (e.g., “I feel alive and vital,” “I have energy and spirit,” “I
look forward to each new day”) were used to assess athletes’
subjective feelings of vitality (α = .85). Responses to the statement

stem “At present, I feel . . .” were recorded on a Likert-type scale
from 1 (strongly disagree) to 5 (strongly agree). Item scores were
averaged to form an overall vitality score. The scale has established
reliability and construct validity (Ryan & Frederick, 1997) and has
been used in past sport-injury research (Podlog, Lochbaum, &
Stevens, 2010).
Self-Esteem Scale. The 10-item Self-Esteem Scale was used to
assess injured athletes’ feelings about themselves at the time of
their study participation (e.g., “On the whole I am satisfied with
myself,” “I have a number of good qualities,” “I take a positive
attitude toward myself”; Rosenberg, 1965). Responses to the
statement stem “I currently feel that . . .” were recorded on a
Likert-type scale of 1 (strongly disagree) to 5 (strongly agree).
Item scores were averaged to form an overall self-esteem score
(α = .86). The scale has established reliability and construct validity
(Rosenberg, 1965) and has been adopted by previous sport-injury
researchers (Podlog, Lochbaum, & Stevens, 2010; Wasley & Lox,
1998).
Rehabilitation Adherence Measure for Athletic Training. The
Rehabilitation Adherence Measure for Athletic Training is a 16-
item measure of adherence developed in a college athletic-training
setting (Granquist, Gill, & Appaneal, 2010). The scale contains
three subscales assessing attendance/participation (example item:
“attends scheduled rehabilitation sessions,” α = .75), communica-
tion (example item: “communicates with the athletic trainer if there
is a problem with the exercises,” α = .48), and attitude/effort
(example item: “has a positive attitude during rehabilitation ses-
sions,” α = .84). Given the low alpha score for the communication
subscale, we omitted it from further analysis. The measure was
completed by certified athletic trainers to ascertain their perspec-
tives on athlete adherence. Subscales and the total scale scores have
demonstrated internal consistency and the ability to discriminate
between adherence levels (Clark, Bassett, & Siegert, 2018;
Granquist et al., 2010).
Short-Form McGill Pain Questionnaire. The valid and reliable
Short-Form McGill Pain Questionnaire consists of 15 descrip-
tors (11 sensory, α = .71; 4 affective, α = .68) rated on an
intensity scale (0 = none, 1 = mild, 2 = moderate, or 3 = severe;
Melzack, 1987). Two pain scores were derived from the sum of
the intensity rank values of the words chosen for the sensory and
affective domains. The Short-Form McGill Pain Questionnaire
has shown adequate test–retest reliability in individuals with a
variety of conditions such as osteoarthritis and musculoskeletal
pain and has demonstrated adequate internal consistency
(α > .75; Melzack & Katz, 2001) and content validity (Trudeau
et al., 2012).
Oswestry Disability Index. The Oswestry Disability Index is a
10-item, validated disability measure assessing perceived func-
tional ability (example item: “I can lift only very light weights,”
α = .74; Fairbank, Couper, Davies, & O’Brien, 1980). Participants
responded to 10 sections (i.e., pain intensity, personal care, lifting,
walking, sitting, standing, sleeping, sex life [if applicable], social
life, traveling) in which they are asked to “tick one box only in each
section that most closely describes you today.” For each section the
total possible score was 5: If the first statement was marked,
the section score was 0; if the last statement was marked, it was 5.
The disability scores range from 0 to 100%, with higher scores
indicating greater disability. The instrument has been widely used
in previous rehabilitation research (Fairbank & Pynsent, 2000;
Podlog et al., 2019).
(Ahead of Print)
Cognitive-Behavioral Injury Intervention 5
Procedure
After we received institutional-review-board approval for the
study, participants completed the informed-consent procedures.
They were assigned on a rolling basis to either the control (n = 8) or
experimental group (n = 8) as described previously. Questionnaires
assessing psychological well-being and clinical outcomes (pain
and perceived function) for experimental- and control-group par-
ticipants were administered by a research assistant during the first
week of rehabilitation (T1), at the rehabilitation midpoint (T2;
identified by the treating certified athletic trainer), and on medical
clearance to return to play (T3). Adherence was assessed by the
treating athletic trainer at T2 and T3. While participants’ length of
recovery varied as a function of their injury type and severity, all
participants completed T1–T3 measures at approximately the same
stage of their rehabilitation and return to play. Moreover, since we
assessed our dependent outcomes of interest over the duration of
athletes’ full rehabilitation program (i.e., until they were medically
cleared to return to sport), we were able to determine the actual
length of each athlete’s recovery time. Based on this, the treating
athletic trainers’ accuracy in their projections of T2 being close to
the actual midpoint of rehabilitation was decided by the authors to
be methodologically acceptable (within 1 week from participants’
actual rehabilitation midpoint). Questionnaires were completed
during athletes’ regularly scheduled rehabilitation session, and
all responses were kept confidential per ethics guidelines.
Statistical Analysis
Data were screened for outliers using box plots and z scores (using
a ±3.0-z cut point) and checked for Gaussian distribution using
k-density plots. No data within any dependent variable met the
criteria for a potential outlier, so all were included in the analyses.
Baseline differences between experimental and control groups
were analyzed using independent t tests. To examine differences
between experimental and control groups at the T2 and T3 time
points, analysis of covariance (ANCOVA) tests were employed,
controlling for scores at baseline. This method was used to address
a conditional research question assuming no differences among
dependent-variable scores at T1 (Fitzmaurice, 2001). Because there
were no statistical differences between experimental and control
groups at T1, the T1 covariate reduced baseline random noise,
thereby potentially increasing statistical power and improving
internal validity. The between-groups assumption of homogeneity
of variance was examined using Levene’s test, and the ANCOVA
assumption of homogeneity of regression slopes was examined by
testing the statistical significance of a T1 × Group interaction term.
The initial alpha level for all statistical analyses was set at p < .05,
and effect sizes were estimated using partial eta-squared (η2).
Manipulation Check
A manipulation check was conducted by ascertaining athlete
perceptions of how much their treatment during rehabilitation
focused on features present in the CBT training and presumably
not present among those receiving physical rehabilitation only
(control group). A statement asking participants to “Rate the extent
to which your rehabilitation helped you to . . .” was followed by
items including “learn more about the nature of your injury,
manage worries and expectations,” “shift your focus from negative
to positive thoughts,” “manage emotions,” and “work through
pain.” All responses were recorded on a Likert scale ranging
from 1 (very unhelpful) to 5 (very helpful). A grand mean score
6 Podlog et al.

of the average of responses on all five items was calculated, with
responses showing high internal consistency (α = .866). A t test
revealed that the experimental group scored significantly higher
than the control group on this measure (intervention M = 4.28,
SD = 0.89; control M = 3.47, SD = 0.51), t(14) = −2.21, p = .04,
suggesting the effectiveness of the CBT intervention in promoting
the intended psychological skills. We also assessed the extent to
which experimental-group members (n = 8) completed the home-
work assigned on the five requested occasions. On average,
participants reported completing 4.63 of the 5 homework assign-
ments (SD = 0.48), indicating fairly high self-reported adherence to
the intervention.
Results
Descriptive statistics across all time points for each dependent
variable are provided in Table 1. There were no statistically
significant differences between groups at the T1 on any dependent
variables. Table 2 presents the results from the ANCOVA tests for
each dependent variable. ANCOVAs revealed significant group
differences, with the intervention group displaying higher adjusted
positive affect means at T2 (adjusted mean difference = 0.41,
p = .04, η2p = .34) and T3 (adjusted mean difference = 0.67,
p < .001, η2 = .70; Figure 1). Additional group differences were
observed at T3, with the intervention group displaying lower
adjusted negative affect means (adjusted mean difference =
− 0.81, p = .01, η2 = .47; Figure 2), represented by a large effect
size, and higher adjusted vitality means at T2 (adjusted mean
difference = 0.99, p = .01 η2 = .48) and T3 (adjusted mean differ-
ence = 1.08, p = .02, η2 = .33; Figure 3), represented by large effect
sizes. There were no statistically significant Group × Time inter-
actions for disability (p = .49, η2 = .21), sensory pain (p = .57,
η2 = .10), affective pain (p = .36, η2 = .15), self-esteem (p = .99,
η2 < .001), or Rehabilitation Adherence Measure for Athletic
Training (p = .82, η2 < .001).
Discussion
We examined the efficacy of a CBT-based intervention for
enhancing the well-being, rehabilitation adherence, and clinical
outcomes of athletes with injuries using a quasi-experimental
design. The current study was an attempt to add to the relatively
limited body of psychological interventions with NCAA Divi-
sion I athletes with severe injuries. As noted by Simpson
and Post (2014), challenges associated with recruitment of
busy student-athletes for participation in intervention research
(engagement in treatment sessions and completion of repeated-
measure designs) are a likely reason why there are so few
psychological interventions with college athlete cohorts. As
such, the present study adds to the literature by providing
evidence for the value of an ecologically valid CBT-based
intervention that addresses scheduling constraints and allows
for flexible service delivery.

Table 1 Descriptive Statistics Across All Time Points, M (SD)

Time Total sample, Control group, Intervention group, Baseline group
point N = 16 n=8 n=8 difference, p
Positive affect T1 3.12 (0.57) 3.04 (0.60) 3.21 (0.57) .60
T2 3.45 (0.49) 3.21 (0.32) 3.70 (0.53)
T3 3.91 (0.46) 3.54 (0.29) 4.28 (0.23)
Negative affect T1 3.03 (0.73) 3.21 (0.63) 2.85 (0.82) .38
T2 2.57 (0.81) 2.91 (0.63) 2.24 (0.87)
T3 2.31 (0.61) 2.72 (0.52) 1.90 (0.37)
Vitality T1 3.63 (0.95) 3.42 (0.90) 3.83 (1.03) .41
T2 4.24 (0.73) 3.75 (0.50) 4.73 (0.56)
T3 4.86 (0.94) 4.34 (0.72) 5.39 (0.87)
Disability T1 2.12 (0.51) 2.30 (0.35) 1.40 (1.40) .92
T2 1.58 (0.56) 1.63 (0.64) 1.40 (1.40)
T3 1.28 (0.36) 1.35 (0.37) 1.00 (1.00)
Sensory pain T1 0.87 (0.52) 0.95 (0.59) 0.77 (0.44) .34
T2 0.43 (0.30) 0.38 (0.27) 0.51 (0.34)
T3 0.16 (0.14) 0.14 (0.15) 0.20 (0.15)
Affective pain T1 0.42 (0.53) 0.31 (0.42) 0.53 (0.65) .44
T2 0.22 (0.20) 0.19 (0.18) 0.25 (0.23)
T3 0.14 (0.26) 0.03 (0.08) 0.25 (0.33)
Self-esteem T1 2.02 (0.34) 2.21 (0.34) 1.78 (0.64) .13
T2 1.90 (0.52) 2.09 (0.40) 1.65 (0.60)
T3 1.83 (0.46) 2.01 (0.39) 1.60 (0.45)
RAdMAT total T2 44.56 (4.37) 42.62 (4.34) 46.50 (3.66) .07
T3 41.81 (4.85) 39.62 (3.33) 44.00 (5.31)
Note. T1 = baseline; T2 = rehabilitation midpoint; T3 = medical clearance to return to play; RAdMAT = Rehabilitation Adherence Measure for Athletic Training.
Adherence (RAdMAT) was assessed at T2 and T3. As such, there are no T1 adherence scores.

(Ahead of Print)
 Cognitive-Behavioral Injury Intervention 7

Table 2 Experimental-Group Main Effects

From the Analysis-of-Covariance Tests Using
a Baseline-Score Covariate
Dependent variable Time point F p η2p
Positive affect T2 5.78 .04* .34
T3 26.06 <.001* .70
Negative affect T2 1.65 .23 .13
T3 9.92 .01* .47
Vitality T2 12.19 .01* .48
T3 6.50 .02* .33
Disability T2 0.04 .85 .01
T3 0.29 .68 .10
Sensory pain T2 1.60 .23 .12
T3 0.19 .67 .02
Affective pain T2 0.05 .83 .00
T3 2.38 .15 .16
Self-esteem T2 0.23 .64 .02 Figure 2 — Mean negative affect (Likert scale from 1 [very slightly or
not at all] to 5 [extremely]) across intervention time points by group.
T3 0.74 .41 .06
T1 = baseline; T2 = intervention midpoint; T3 = intervention end point.
RAdMAT total T3 1.09 .32 .08
Note. η2p = effect-size metric partial eta-squared; T2 = rehabilitation midpoint;
T3 = medical clearance to return to play; RAdMAT = Rehabilitation Adherence
Measure for Athletic Training. As there were no baseline scores for adherence
(RAdMAT), T2 RAdMAT scores were used as the ANCOVA covariate; hence
only T3 scores are reported.
*Significant at p < .05.

Figure 3 — Vitality across intervention time points by group.

CBT = cognitive-behavioral therapy; T1 = baseline; T2 = intervention
midpoint; T3 = intervention end point.

Figure 1 — Mean positive affect (Likert scale from 1 [very slightly or

not at all] to 5 [extremely]) across intervention time points by group.
T1 = baseline; T2 = intervention midpoint; T3 = intervention end point.
We hypothesized that both control and experimental groups
would demonstrate improvements over time in relation to our
outcome variables. As shown in Table 1, findings supported this
hypothesis, with improvements in psychological well-being and
clinical function (i.e., decreases in disability) documented
across time for both groups. Furthermore, we anticipated that
athletes in the experimental condition would show improved
(Ahead of Print)
well-being, rehabilitation adherence, and clinical outcomes
compared with athletes in the control group receiving a program
of physical rehabilitation only. Moderate support was found
for this hypothesis, with athletes in the experimental condition
showing greater well-being (enhanced affect, vitality, self-
esteem) relative to control-group members. In particular,
increased positive affect and vitality at the T2 and T3 and
diminished negative affect at T3 were documented, with large
effect sizes. These findings support the value of multimodal
psychological interventions such as CBT for enhancing pleas-
ant/adaptive, and decreasing unpleasant/maladaptive, emotions
during the rehabilitation period.
8 Podlog et al.
Researchers have previously demonstrated a predominance of
unpleasant emotions (e.g., anger, anxiety, depression, isolation) after
initial injury occurrence and rehabilitation setbacks (Ruddock-
Hudson et al., 2012; Tracey, 2003), as well as the deleterious impact
of negative emotions on the healing processes (Gouin & Kiecolt-
Glaser, 2011) and rehabilitation adherence (Brewer, Cornelius, &
Van Raalte, 2013). Findings regarding improved psychological
well-being outcomes in the CBT intervention group are valuable
in three respects. First, although psychological interventions have
demonstrated efficacy in past research (Evans & Hardy, 2002;
Johnson, 2000; Maddison et al., 2012), relatively few well-
controlled studies have been implemented (Brewer & Redmond,
2016; Schwab Reese et al., 2012). Although we adopted a quasi-
experimental versus true-experimental design, our investigation adds
to the relatively modest body of psychological-intervention research
by demonstrating the value of a CBT-based intervention in facilitat-
ing emotional adjustment after sport injury.
Second, our findings provide further support for the value of
multimodal interventions (Evans & Hardy, 2002; Evans et al., 2000;
Johnson, 2000) for enhancing the well-being of injured athletes
during injury rehabilitation. An important advantage of multimodal
interventions is that they provide injured athletes a variety of
cognitive-behavioral strategies and the ability to use a particular
method if other approaches in the intervention armory are not
personally appealing (Brewer & Redmond, 2016). Ultimately, the
intervention strategies employed should address the specific stres-
sors experienced by athletes with particular injury types (Petrie,
Tomalski, & Clevinger, 2020). For instance, Petrie et al. (2020)
suggest two broad categories of psychosocial intervention—
instrumental and relational interventions—that serve potentially
different functions for athletes with injuries. Instrumental interven-
tions refer to tangible strategies (e.g., goal setting, imagery, self-talk)
designed to facilitate physical recovery and help athletes take
ownership of their recovery. Relational interventions such as social
support and formal counseling can be used to help improve psy-
chological recovery by helping athletes feel cared for and connected
to significant others. While multimodal interventions may help
address a multitude of stressors and serve a variety of functions,
one limitation of such intervention programs is that it is unclear
which particular strategy or technique accounts for resulting effects.
For example, one of the strategies employed in the current investi-
gation that has previously shown promise is written emotional
disclosure (Mankad et al., 2009). While it seems likely that the
writing exercise conducted in this study had positive implications for
athletes’ emotional status, the multimodal nature of our intervention
prevents firm conclusions on this account.
Third, previous work has demonstrated the value of psycho-
logical interventions for a variety of sport-injury outcomes such
as athlete mood states, pain, self-efficacy, reinjury anxiety, and
knee laxity (Cupal & Brewer, 2001; Evans et al., 2000; Johnson,
2000; Maddison et al., 2012). However, researchers have yet to
demonstrate the value of multimodal intervention strategies with
regard to the specific emotions examined in this study, namely,
increases in positive (pleasant) affect and vitality and reductions
in negative affect. In regard to vitality, evidence suggests that it
has protective effects in augmenting personal health and well-
being (Penninx et al., 2000; Strijk, Proper, Beek, & Mechelen,
2012) and may be particularly salient for athletes who have
sustained long-term injuries, whose motivation levels may
decrease over a prolonged rehabilitation (Levy, Polman,
Nicholls, & Marchant, 2009). Given the lengthy period of reha-
bilitation for participants in this study (M = 13.31 weeks), findings
(Ahead of Print)
from this investigation suggest that relatively brief interventions
(4 weeks long) may have sustained impact for the affective states
and vitality of injured athletes. These findings bolster those of
Johnson (2000), who also found that a short-term multimodal
intervention (stress management and cognitive control, goal
setting, and relaxation/guided imagery) helped elevate positive
mood in competitive athletes with long-term injuries. Further
research is needed to better ascertain dose-response effects (how
much and for how long) regarding psychological interventions for
athletes with long-term injuries.
No statistical support was found for between-groups differences
in rehabilitation adherence or clinical function, perhaps because
rehabilitation protocols are already well addressed in the university’s
established athlete injury-intervention programs. Specifically, ath-
letes in both conditions were involved in structured rehabilitation
where extensive support systems were available (e.g., sport and
clinical psychologists, nutritionists, strength and conditioning ex-
perts), and athletes had regular contact with experienced athletic
trainers who held them accountable for their rehabilitation efforts.
This suggestion is supported by Brewer (2010), who asserted that
there is a strong tendency for athletes to attend their scheduled
rehabilitation appointments. In the current study, we suspect that
functional capabilities after injury recovery did not differ as a result
of group membership given the nonsignificant differences between
groups in rehabilitation adherence. For example, in previous work,
rehabilitation adherence has been associated with enhanced func-
tional ability after severe injury (Alzate Saez de Heredia et al., 2004;
Brewer et al., 2004; Pizzari et al., 2005).
Several limitations are evident in the current investigation.
First, although our power analysis revealed that our sample size of
16 participants was adequate for achieving 80% statistical power, it
is possible that the relatively small sample size could nonetheless
account for the lack of between-groups differences in adherence
and clinical function. Researchers are encouraged to obtain larger
sample sizes in future intervention research.
Second, as indicated, our control group performed physical
rehabilitation only. To better control for the nonspecific effects of
the experimental treatment (e.g., the fact that the experimental
group received social support in the form of interaction with a
treatment provider), it would have been valuable to recruit an
attention-control group. For instance, it is possible that the “act” of
receiving support or time spent with the treatment provider—rather
than the actual CBT-based skills—may have accounted for some of
the observed well-being effects. Recruitment of an attention-
control group (e.g., providing injured athletes with reading materi-
als on recovery, videos, various forms of social support) is
therefore advocated for future work in this area.
Third, the quasi-experimental design and heterogeneity of
injuries are also potential issues that could have influenced the
findings. As indicated, given our interest in minimizing potential
interactions and sharing of information between experimental-
and treatment-group athletes, we intentionally assigned partici-
pants to the experimental group and on completion of their
rehabilitation began enrolling athletes into the control group.
If, or when, circumstances permit (e.g., situations where con-
tamination effects are unlikely), researchers are encouraged to
adopt true experimental designs. Along these lines, to whatever
extent pragmatic considerations allow, it would be valuable to
work with participants with similar injury types and severities to
reduce the potential confounding influence of such variables on
outcomes of interest (e.g., well-being, adherence, clinical/func-
tional ability).

A fourth potential limitation relates to the fact that different
athletes were treated by different athletic trainers throughout their
rehabilitation, an issue that may have influenced the types of
interactions between athletes and their treatment providers, thereby
influencing treatment perceptions and rehabilitation experiences/
outcomes. This issue, however, may be an inherent feature of
research with NCAA Division I athletes, many of whom likely
rehabilitate in environments where different athletic trainers may
be assigned to different sports.
Fifth, our use of a single- versus double-blind design may be a
limitation insofar as athletic trainers’ knowledge of the purposes of
the study and participant allocation to experimental/control groups
may have influenced the former’s treatment of, or interactions with,
athletes.
Sixth, it is possible that previous exposure to mental-skills
training differed between experimental conditions at baseline, a
possibility we did not assess in the current study, and one that might
have influenced our findings.
A seventh limitation pertains to the fact that it would have
been informative to report athletes’ self-assessment scores on their
knowledge and ability of the CBT intervention skills. Although the
scores were given to the athletes in the experimental group and
used for discussion purposes, we did not retain these scores for
reporting in the manuscript.
A final limitation of our study relates to the fact that the
intervention period of 4 weeks was relatively brief. Had experi-
mental-group athletes had more prolonged engagement with the
skills, they might have experienced greater benefit and hence
change in behavioral (adherence) or clinical outcomes of interest
(pain, functional ability). Along these lines, it is possible that some
athletes in the experimental group made more extensive use of the
CBT skills after completion of the individual 4-week intervention.
As such, it is hard to say whether differences in the amount of
engagement with the skills after completion of the intervention time
period affected athlete responses to outcomes of interest over the
course of their respective rehabilitations (i.e., at T2 and T3 follow-
up assessments). Interventions of potentially longer durations
might be warranted to further examine the impact of CBT-skills
training on injured athletes’ well-being, adherence, and functional
outcomes.
The limitations of this study notwithstanding, findings from
the study can advance research and applied practice in several
respects. While our adoption of a quasi-experimental design
appeared more rigorous than some studies—but less rigorous
than true experimental studies—we nonetheless provided further
support for the value of a CBT-based psychological intervention
relative to the well-being outcomes. These data suggest that
changes in affect should be a priority for rehabilitation programs,
because other downstream behavioral outcomes likely depend on
athletes’ maintaining adaptive emotional profiles needed to perse-
vere through the stressors inherent in the rehabilitation process. On
a practical level, the program that we used to implement the CBT
skills in the current study lends itself to instruction and implemen-
tation with sport psychology and sports-medicine professionals,
who can, in turn, deliver skills to injured athletes in the context of a
rehabilitation session. Finally, adoption of a multimodal interven-
tion provides athletes options and choices that may increase their
receptivity and use of CBT skills during sport-injury rehabilitation.
Future work should seek to examine how to create the right
“medley” of psychological-skills training to develop adaptive
emotional profiles, enhance physical and psychological recovery,
and improve return-to-play outcomes in elite-level athletes.
(Ahead of Print)
Cognitive-Behavioral Injury Intervention 9
Conclusions
Our data provide support for use of a CBT-based intervention in
facilitating emotional well-being in injured athletes. Given the
acknowledged stressors of injury rehabilitation, as well as the link
between ongoing negative affect and maladaptive rehabilitation
outcomes (Brewer et al., 2013; Tracey, 2003), improving positive
emotional adjustment is of clear clinical importance for injured
athletes. Findings from the current study suggest that rehabilita-
tion practitioners may increase athlete well-being through the use
of easily implemented strategies such as injury-education heur-
istics, written emotional-disclosure exercises, scripted relaxation,
imagery, and cognitive reframing strategies. Sample materials are
available from the corresponding author on request. In addition,
by increasing athletes’ positive affect and vitality over the course
of rehabilitation, practitioners may facilitate adherence, motiva-
tion, and persistence in the face of rehabilitation challenges and
setbacks. Finally, from a practical standpoint, multimodal CBT
interventions such as those implemented in the current study may
be valuable in providing athletes options and choices that increase
adoption and use of psychological skills during sport-injury
rehabilitation. Despite important findings from the current study,
further randomized controlled trials are needed to examine the
value of psychological interventions in addressing important
rehabilitation outcomes.
Acknowledgments
We would like to acknowledge the Association for Applied Sport Psy-
chology (AASP) for funding the current study. Special thanks also go to
the athletes participating in this investigation.
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