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The effectiveness of imagery on pain, edema, and range of motion in athletes

with a grade II ankle sprain

Article in Physical Therapy in Sport · August 2007

DOI: 10.1016/j.ptsp.2007.03.005

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 ARTICLE IN PRESS

Physical Therapy in Sport 8 (2007) 130–140

www.elsevier.com/locate/yptsp

Original research

The effectiveness of imagery on pain, edema, and range of motion in

py
athletes with a grade II ankle sprain
Anna Christakou, Yannis Zervas

co
Department of Physical Education and Sports Science, University of Athens, 41 Ethnikis Antistaseos str., 172 37 Dafne, Athens, Greece
Received 16 February 2006; received in revised form 21 March 2007; accepted 27 March 2007

Abstract

al
Objectives: To examine the effectiveness of imagery on pain, edema, and range of motion in athletes who have sustained a grade II
ankle sprain.
on
Participants: The sample consisted of 18 active male athletes, aged from 18 to 30 years, with a grade II ankle sprain, confirmed by
ultrasound testing. The participants were randomly divided into two conditions: a relaxation and imagery condition (n ¼ 9) and a
control condition (n ¼ 9). The participants in the relaxation and imagery condition received 12 individual sessions of imagery
rehearsal in addition to a normal course of physiotherapy, while the participants in the control condition followed only the
physiotherapy treatment.
rs

Main outcome measures: Participants were administered a Visual Analogue Scale (VAS) in order to measure acute pain intensity.
Edema was evaluated with the water volumetric displacement method. Ankle range of motion (ROM) was assessed using a
goniometer.
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Results: The study did not show demonstrable effects on pain, edema, and ROM after the application of imagery treatment.
Conclusions: Further research could examine the relationship between different types of imagery and rehabilitation from sport
injury using standardized imagery instruments.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: Imagery; Pain; Edema; Range of motion; Ankle sprain

r's

1. Introduction Gilmore, & Wiggam, 2004; Page, Levine, Sisto, &

Johnston, 2001; Syrjala, Donaldson, Davis, Kippes, &
Mind–body therapies based on cognitive-behavioural, Carr, 1995; Utah & Miller, 2006). This study examined
o

psychological, social and spiritual approaches have been possible therapeutic effects of imagery on pain, edema,
used widely for the management of medical conditions and range of motion (ROM) on ankle sprain grade II.
th

(Coker, 1999; Hadhazy, Ezzo, Creamer, & Berman, A number of explanations have been proposed to
2000; Lorig & Holman, 1993). In particular, imagery is a interpret the effectiveness of imagery on recovery
mind–body/psychological technique that has been used outcomes. One explanation is based on the physiological
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as an ‘‘alternative’’ (i.e., instead of) or ‘‘complementary’’
(i.e., addition to) to the conventional medical interven-
tions for over a century in health care (Astin, Beckner,
Soeken, Hochberg, & Berman, 2002; Crosbie, McDonough,
Corresponding author. Tel.: +30 2107276052;
fax: +30 2107276054.
E-mail address: achristakou@hol.gr (A. Christakou).
state of hypoarousal that frequently results from
imagery practice (i.e., attenuation of sympathetic
arousal, which may diminish pain and evoke psycho-
physiological regulation and balance) (Benson, 1975;
Jacobs, Benson, & Friedman, 1996; Lazar, Bush,
Gollub, Fricchione, Khalsa, & Benson, 2000). A second
explanation for the role of imagery on pain management
is given by the gate control theory (Melzack, 1999, 2001;

1466-853X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2007.03.005
 ARTICLE IN PRESS
A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140
Melzack & Wall, 1965). In gate control theory, the brain
is an active system that filters, selects and modulates
inputs (Melzack, 1999). Melzack proposed that pain
modulation occurs through an interrelationship of two
components of the pain system, the sensory-discrimina-
tive and the motivational affective. In particular, the
motivational-affective component is related to the
limbic system of the brain and impulses arising from
the periphery can either be increased or decreased
according to the output from the central circuit (i.e.,
impulse transmission is either facilitated or inhibited at
the level of the spinal cord). That is, if impulse
transmission is sufficiently inhibited at that level, then
the gate is closed (i.e., the perception of pain, which
occurs in the brain, is blocked). Imagery through
relaxation may block thoughts of pain, therefore,
decreasing the perception of the pain, and may diminish
the amount of painful stimuli sent to the brain. A third
explanation refers to the increase of endorphins through
the procedure of relaxation which occurs during imagery
treatment. Endorphins are endogenous opioid-peptide
compounds that are found in several areas of the brain,
on
spinal cord, and peripherally. The release of endorphins,
by interneurons in the dorsal horn of the spinal cord,
diminishes the sensation of pain via presynaptic inhibi-
tion of the afferent neurons projecting to the brain
rs
(Ganong, 2003; McCance & Huether, 2002; Rosenzweig,
Leiman, & Breedlove, 1999).
Research has shown that imagery is effective as a
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pain-management technique for rheumatoid arthritis
(Astin et al., 2002; Walko, Varni, & Ilowite, 1992),
osteoarthritis (Baird & Sands, 2004; Lorig & Holman,
1993; Lorig, Manzonson, & Holman, 1993), fibromyal-
gia (Hadhazy et al., 2000), cancer (see systematic review,
Roffe, Schimdt, & Ernst, 2005), headache (Ilacqua,
1994), and acute (Manyande et al., 1995) or chronic pain
r's
(Akerman & Turkoski, 2000; Korn, 1983; McKee, 1984;
Nicol, 1993; Sthalekar, 1993) experienced due to other
medical conditions. Also, imagery with relaxation has
been used effectively in children with malignancies to
o
help reduce the pain and discomfort from treatment
procedures, such as bone marrow, chemotherapy,
th
radiation, blood-drawing, lumbar punctures, and in-
travenous injections (Hobbie, 1989).
Accordingly, imagery techniques can be used in the
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rehabilitation process of sport-related injuries (Cupal &
Brewer, 2001; Green, 1999; Heil, 1993; Richardson &
Latuda, 1995; Sordoni, Hall, & Forwell, 2000, 2002;
Taylor & Taylor, 1997). Botterill, Flint, and Ievleva
(1996) identified four basic types of imagery that may be
applied during sport injury rehabilitation: healing
imagery, performance imagery, recovery or affirmation
imagery, and treatment imagery. In particular, in
treatment imagery, injured athletes imagine the efficient
and quick results of the physiotherapy treatment. For
example, imaging and feeling the physiotherapy treat-
131
ment may contribute to the increase of muscle’s
strength. This increase may be due to neural changes
in central processes of motor system (Annett, 1995;
Jeannerod, 1995). Imagery rehearsal trains higher-order
motor cortical regions and prefrontal areas which could
generate stronger signals to the primary motor cortex
and the motor neuron pool. This could result in stronger
signals from the motor neurons to the target muscles
py
leading to greater muscular activation (Ranganathan,
Siemionow, Liu, Sahgal, & Yue, 2003). Recently,
Morris, Spittle, Watt, and Walsh (2005) reported four
categories of imagery used in rehabilitation of a sport
co
injury: healing imagery, pain-management imagery,
rehabilitation-process imagery, and performance ima-
gery. In particular, pain-management imagery helps
injured athletes cope with the pain of injury. This type of
imagery includes six pain-management techniques from
which pleasant and neutral imagining (dissociative
imagery techniques) are used in the present study. For
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example, injured athletes imagine and feel themselves in
a relaxing and comfortable setting (e.g., lying on a
beach) or dressing calmly before or after a competition
or practice.
Heil (1993) reported that imagery could be used as a
pain-management technique for sport injury. Similarly,
Ievleva and Orlick (1999) mentioned that athletes could
imagine cool colours, soothing and reducing any
inflammation and pain, the pain leaving the body, and
the ice-pack over the painful area. Sthalekar’s (1993)
study showed that an 8-week hypnotherapy program,
including imagery, relaxation, and positive suggestions,
contributed to less phantom pain in the injured limb and
the athlete was able to resume some of the preaccident
activities. In another study, Nicol (1993) indicated that a
person with repetitive strain injury had less pain and
inflammation after hypnotic relaxation, imagery, and
counselling. Cupal and Brewer’s (2001) study, however,
is the only true experimental investigation to date.
Cupal and Brewer examined the effectiveness of relaxa-
tion and guided imagery on 30 athletes who followed
post surgical rehabilitation treatment after anterior
cruciate ligament reconstructive surgery. The findings
showed that the treatment group had significantly
greater knee strength, less re-injury anxiety, and less
pain at 24 weeks post surgery than participants in
the placebo and control groups over the course of
rehabilitation.
There has been little experimental research evaluating
the efficacy of imagery for pain management of sport
injuries. In particular, few studies have reported the
effectiveness of pain-management imagery on a sport
injury (Cupal & Brewer, 2001; Sthalekar, 1993). Thus, it
is necessary to conduct more experimental studies. In
addition, there have not been studies examining the
role of imagery on the variables of edema and ROM
in athletic or other clinical populations. Udry and
 ARTICLE IN PRESS
132 A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140
Andersen (2001) reported that further research should
be conducted on the influence of psychological factors,
such as imagery, on recovery outcomes among injured
athletes (e.g., ROM). Furthermore, experimental studies
have to investigate the impact of imagery on the
rehabilitation process of an ankle injury, which is one
of the most frequent injuries in organized sport world-
wide (Lassiter, Malone, & Garrett, 1989; Smith &
Reischl, 1986). Moreover, there is lack of experimental
research confirming the psycho-physiological processes
of imagery on the recovery outcomes of sport injury
rehabilitation. Examining the processes which take place
in sport injury is not only a question of theoretical
importance, but also one which has clinical relevance.
Such knowledge might help physiotherapists and
coaches to maintain athletes’ pre-injury performance
levels; that is the inhibition of athletes’ reduction of
muscle strength, balance, ROM, and functional ability
during the rehabilitation process. Furthermore, phy-
siotherapists and coaches might speed up the recovery
time due to the reduction of pain and edema. Also, using
imagery as part of the rehabilitation process, may
on
improve the general physical well being of athletes.
Finally, in the present study, imagery has been used as
complementary therapy to the conventional treatment.
The use of this therapy may help injured athletes
rs
undergoing the necessary standard rehabilitation treat-
ment and to enhance their quality of care; thus a wide
variety of health techniques is available to injured
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athletes.
The purpose of this study was to examine the effects
of treatment and pain-management imagery on pain,
edema, and ROM in athletes with acute grade II ankle
sprain. It was hypothesized that the relaxation and
imagery participants who received imagery treatment in
addition to the physiotherapy course would have lower
r's
pain and edema, and higher ROM than the control
group after 4 weeks of treatment.
o
2. Method
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2.1. Participants
Fifty-two athletes with an ankle sprain were initially
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evaluated objectively by a physician in a private
clinic with the use of ultrasound. Twenty-six of
them met the inclusion criteria and 18 agreed to
participate in the study. The objective evaluation of
the injury was done 5 days (mean ¼ 5.00 days,
SD ¼ 2.49 days) after the injury day. All participants
had a grade II ankle sprain in the left or right leg, which
could be either the dominant or the nondominant leg.
Sixteen of them had a tear of the anterior and posterior
talofibular ligament and two athletes had a tear of the
deltoid ligament.
Thus, the final sample consisted of 18 volunteer,
injured, male athletes with an ankle sprain grade II,
aged from 18 to 30 years (mean ¼ 26 years, SD ¼ 4.47
years), with at least two years of athletic experience
(mean ¼ 2.56 years, SD ¼ .78 years). Participants were
randomly divided into two conditions by the method of
drawing lots: a relaxation and imagery condition and a
control condition. Each condition consisted of nine
py
participants. The leg dominance for all participants was
the right limb. Five participants of each condition had
the right limb injured. The injured athletes had
experienced their ankle sprain injury while participating
co
in volleyball (n ¼ 4), basketball (n ¼ 4), soccer (n ¼ 3),
mini-soccer (n ¼ 2), and other sport activities (n ¼ 5).
The age of participants in the relaxation and imagery
condition ranged from 18 to 30 years (mean ¼ 25.44
years, SD ¼ 4.82 years) and in the control condition
from 19 to 30 years (mean ¼ 26.55 years, SD ¼ 4.30
years).
al
All participants were informed about the procedures
of the study and signed a written, informed consent
form. Institutional ethical approval was obtained
through the Department of Exercise and Sport Science,
University of Athens. In order for participants to be
included in the study, they had to meet the following
criteria: (i) have a grade II ankle sprain, confirmed by
ultrasound (Siemens 2000-SK) carried out by the same
physician in a private clinic (grade II ankle sprain is a
partial macroscopic ligament tear with moderate pain,
swelling, and tenderness over the involved structures
with some loss of motion and mild or moderate
instability of the joint, Kaikkonen, Kannus, & Jarvinen,
1994; Lynch & Renstrom, 1999), (ii) have no history of
previous sprain in either ankle, (iii) have followed
conservative medical care in a public hospital or a
private clinic on the day of injury (including plaster
immobilization, adhesive strapping, or elastic banda-
ging), and (iv) have been active in sports activities at
least three times weekly during the past two years.
2.2. Design
This study employed an experimental design, compar-
ing a relaxation and imagery condition and a control
condition. The study included a manipulation check of
imagery treatment, the Vividness Movement Imagery
Questionnaire, and measurement of the dependent
variables, namely pain, edema, and ROM at five
occasions during rehabilitation.
2.3. Measures
Pain of the injured leg, edema and the ROM of both
legs were measured, in total, five times during the
rehabilitation period for all participants (i.e., in the
beginning of the first physiotherapy session, at the end
 ARTICLE IN PRESS
A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140
of the last physiotherapy session and in the beginning of
every fourth physiotherapy session).
2.4. Pain
Participants completed a Visual Analogue Scale
(VAS) in order to measure acute pain intensity. The
VAS is a horizontal 10-cm line with defined boundaries,
labeled ‘‘no pain’’ (0) and ‘‘severe pain’’ (10). The major
advantage of VAS measure of pain intensity is its ratio
scale properties, which imply equality of ratios, thus,
allowing one to compare percentage differences between
VAS assessments made over time (Price & Harkins,
1987). The VAS pain measure provides a simple and
efficient measure of pain intensity widely used in pain
research (Cross, Worrell, Leslie, & Van Veld Khalid,
2002). It offers a quick assessment of pain, and high
association with pain measured on verbal and numeric
pain-rating scales (Ekblom & Hansson, 1988). Its
reliability and validity have been previously addressed
(Badia, Monserrat, Roset, & Herdman, 1999; Hoker,
Munster, Klein, Eppasch, & Tiling, 1995; Price,
on
McGrath, Rafii, & Buckingham, 1983).
2.5. Edema
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Edema was evaluated with the water volumetric
displacement method, based on Archimedes theory, by
the physiotherapist. In particular, a circular Plexiglas
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ankle volumeter was used for the volumetric measure-
ments. The displaced volume of water was discharged
through an overflow spout, captured in a basin, and
transferred to a 1.000-ml graduated cylinder for
measurement. Water temperature was maintained at a
constant at 27–30 1C (skin temperature) and was
measured prior to each measurement. Swelling was
r's
computed by subtracting the volume of the uninvolved
ankle from that of the injured one (Wilson &
Gansneder, 2000). Cloughley and Mawdesely (1995)
reported a high reliability index for the water volumetric
o
displacement method (ICC ¼ .96). Similar reliability
indexes were found by Wilson, Gieck, Gansneder,
th
Perrin, Saliba, and McCue, (1998) and Petersen et al.
(1999).
The participants, while sitting on a rolling stool with
Au
the knee and hip flexed to approximately 901, were
instructed to gently place their foot in the volumeter so
that their toes just touched the front wall. A thin coat of
water was applied to the limb before immersion to
minimize the amount of air trapped around leg hair. The
participants, then, lowered their foot slowly down to the
bottom of the volumeter without bearing weight on their
foot. While leaving their foot in place, they slowly slid
the rolling stool backwards until their calf just touched
the back of the volumeter. The participants were
instructed not to move from this position until told to
133
do so by the investigator. A demonstration of the
correct foot placement was performed for each partici-
pant by the investigator before beginning the procedure.
After the measurement was recorded, the participants
were instructed to remove their foot, which was dried
before the next measurement.
2.6. Range of motion
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ROM of the ankle was assessed by a physiotherapist,
using a goniometer and performing three measurements
of the involved and the uninvolved extremity. The
co
investigator recorded the total ROM in plantarflexion
and dorsiflexion in degrees. Motion deficits (ROM loss)
were computed by subtracting total saggital plane
motion measured in the injured ankle from similar
measurements taken from the contralateral limb. Wilson
et al. (1998) reported a high reliability index for this
method (ICC ¼ .88) and it has been used widely in
al
rehabilitation (Eiff, Smith, & Smith, 1994; Wilson &
Gansneder, 2000).
Passive dorseflexion and plantar flexion were recorded
bilaterally. Specific anatomic landmarks were the lateral
malleolus, the lateral aspect of the fifth metatarsal head
and an imaginary line between the lateral malleolus and
the fibular head. Participants were instructed to tell the
investigator of any pain they experienced during the
measurement. If no pain was felt, passive ROM end
points were established by using light manual over-
pressure at the fourth and fifth metatarsal heads.
2.7. Manipulation check
A manipulation check with a Likert scale from 1 (not
at all) to 5 (very much) was used to ascertain whether
participants in the relaxation and imagery condition
were imagining the content of the representation vividly
and truly. The manipulation check consisted of the
following eight questions: (a) Did you feel your body
movements during exercise performance? (b) Did you
watch yourself performing the exercises from a distance?
(c) Did you imagine yourself performing the exercises
from your own eyes? (d) Did you see somebody else
perform the exercises? (e) How vividly did you feel your
exercise performance? (f) How clearly did you feel your
exercise performance? (g) How much did you control
your exercise performance? and (h) How activated did
you feel during imagery?
2.8. Diary of imagery
A diary of imagery was used by participants in the
relaxation and imagery condition to record once daily at
home the session of imagery program. In particular,
participants were asked to perform the same imagery
session that they performed earlier in the physiotherapy
 ARTICLE IN PRESS
134 A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140
clinic. Thus, every week they had to record the content
of the imagery session and the time of performance of
the imagery program at home.
2.9. Vividness of Movement Imagery Questionnaire
Participants in the relaxation and imagery condition
completed the Vividness of Movement Imagery Ques-
tionnaire (VMIQ; Isaac, Marks, & Russsell, 1986) in
order to assess movement imagery. This instrument is
composed of 24 items relevant to movement imagery:
visual imagery of movement itself and imagery of
kinaesthetic sensations. Participants are required to
image each item both with respect to someone else and
themselves. The items fall into six groups of four items
each: (a) items relating to basic movements, (b) items
relating to basic movements with more precision, (c)
items relating to movement with control, but some
unplanned risk, (d) items relating to movement control-
ling an object, (e) items relating to movements, which
cause imbalance and recovery, and (f) items relating to
movements demanding control in aerial situations. The
on
5-point scale of the VMIQ is from 1 (perfectly clear and
as vivid as normal vision) to 5 (no image at all, you only
‘‘know’’ that you are thinking of the skill).
rs
2.10. Treatments
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The physiotherapy program started with the use of
hydro-massage, ultrasound, and a laser device to
decrease the pain and swelling of the ankle. The
physiotherapy program included the following exercises:
(1) a ROM exercises in dorsal and plantar flexion and in
pronation; (2) strengthening exercises of the ankle
(standing on heels and toes, walking on heels and toes,
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hops on one foot, resistance exercises with a latex rubber
band); (3) proprioceptive training, which included (a)
sitting and circularly moving the injured leg on a
balance board, (b) standing with two legs on a balance
o
board with open and closed eyes, (c) standing with one
leg on a balance board with open and closed eyes, (d)
th
exercises on a mini—tramp (standing on two legs,
unilateral stances, hops on two legs and on one leg); (4)
cycling on a stationary bike; (5) forward lunges against a
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wall; (6) step-ups and down on the saggital plane or the
transverse plane; (7) diagonal hops on the ground; and
(8) stretching exercises against a wall (Glasoe, Alley,
Awtry, & Yack, 1999; Hunter & Prentice, 1999).
The imagery program was used to help participants to
see, control, and vividly construct an image with the
mind. Relaxation before imagery facilitates clarity and
vividness of imaginal representations (Akerman &
Turkowski, 2000). Participants in the relaxation and
imagery condition imagined the quick and efficient
recovery of the physiotherapy treatment.
2.11. Procedure
Participants in the relaxation and imagery condition
received individual sessions of imagery in addition to a
normal course of physiotherapy. At the beginning of the
imagery treatment, participants completed the VMIQ.
At the end of every imagery session they completed the
manipulation check. In scoring the imagery manipula-
py
tion check a total score was calculated for eight
questions for each session. In addition, participants
were asked to complete a ‘‘diary of imagery’’ at home.
In the first four sessions of the intervention phase,
co
information was given to participants concerning
imagery, and a brief report on the influence of imagery
on recovery from injury. In particular, during the first
four sessions, participants followed exercises and
instructions designed to develop their imagery skills in
terms of self-perception, vividness, and controllability.
This training was employed to assist participants in
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being able to see, control, and vividly construct an
image.
The relaxation and imagery group underwent 12
individual sessions of imagery, each lasting 45 min.
Before starting the imagery, a relaxation technique was
applied during every imagery training session, after the
end of each physiotherapy session. Thus, participants
were first given relaxation instructions followed by
imagery exercises. In particular, participants sat quietly
in a comfortable position inside the physiotherapy
clinic. They relaxed all their muscles, starting with their
feet and progressing up to their face. Afterwards,
participants underwent an imagery session following
the investigator’s guidance. The content of every
imagery session was similar to the content of the daily
physiotherapy session, that is, the content of physiother-
apy goals. In particular, participants rehearsed the
sequence and the duration of physiotherapy exercises,
and also, the results of the daily physiotherapy program,
i.e., increased ROM, strength, endurance, balance,
functional stability, and decrease of edema. Therefore,
participants in the relaxation and imagery condition
imagined efficient and quick results of the physiotherapy
program (Botterill et al., 1996). Participants were
instructed to imagine themselves while performing the
physiotherapy exercises and feel the movements as
vividly as possible. Also, during the imagery session,
participants were instructed to picture a real or fantasy
place that was peaceful, happy, and relaxing. Then, they
imagined being in this picture. Also, they imagined other
pleasant and neutral images, i.e., feelings of having
performed a task well, celebrating with others following
a victory, and dressing calmly before or after a
competition or practice. These pleasant and neutral
images are dissociative pain-management techniques
(Fernandez & Turk, 1986; Wack & Turk, 1984) that can
be used through imagery in sport injury rehabilitation
 ARTICLE IN PRESS
A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140 135

(Heil, 1993; Taylor & Taylor, 1997). The imagery
sessions were identical for all participants in the
relaxation and imagery condition.
Participants in the relaxation and imagery condition
and the control condition started physiotherapy eight
days (mean ¼ 8.10 days, SD ¼ 2.64 days), and seven
days (mean ¼ 6.50 days, SD ¼ 1.96 days), respectively,
after the day of injury. The duration of the physiother-
imagery ability remained stable and high (Table 1).
Moreover, Cohen’s d effect sizes (Cohen, 1988), that is,
small (.20), medium (.50), and large (.80 and above),
revealed that imagery effects were large only for the first
three imagery sessions (Table 1).
Separate univariate ANOVA tests were conducted to
investigate (a) differences between the relaxation and
imagery condition and control condition in pain, edema

apy program for participants in the relaxation and
imagery condition and the control condition was 34.66
days (SD ¼ 4.33 days) and 33.77 days (SD ¼ 4.57 days),
respectively.
py
and total range of motion and (b) differences between
‘‘measurements’’ and ‘‘conditions’’ in the three afore-
mentioned variables. The results did not reveal sig-
nificant differences between the two conditions (Table 2)

3. Results
Demographic data indicated that all participants were
familiar with imagery techniques, because they used it
during their training program. Possible scores for the
co
and between the five measurements and the two
conditions (Table 3).
Table 3, however, shows a reduction in the mean
value of pain and edema, and an increase in mean value
of the total ROM in the relaxation and imagery
condition in comparison to the control condition. In
particular, participants in the relaxation and imagery

imagery manipulation check ranged from 40 (highest
imagery ability) to 8 (lowest ability). The range of the
mean scores of the imagery sessions of manipulation
check was 26.2–36.4 (mean ¼ 31.88, SD ¼ 3.40). In the
manipulation check, participants felt that the exercise
performance was ‘‘moderately’’ to ‘‘very much’’ vivid
and clear. Paired t-tests were used to determine the
rs
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condition had (a) greater reduction of pain at the second
and third measurements, (b) greater reduction of edema
at the second, third, and fourth measurements, and (c)
on
greater increase of total ROM at the second, third, and
fourth measurements, in comparison to the control
condition.
Cohen’s d effect sizes indicated that the treatment

differences between participants’ ability to perform effects were large for the pain (d ¼ .86) and medium for
imagery rehearsal during the 12 imagery sessions. The the edema (d ¼ .71), and the total ROM (d ¼ .52)
results indicated statistical differences on participants’ (Table 2). Also, Table 3 shows the treatment effects for
pe

ability to produce vivid and clear images only for the the five measurements of pain, edema and total ROM.
first three imagery sessions, and afterwards their Partial variance effect sizes (Z2) were used to
determine the percentage of variation in the data that
Table 1 could be attributed to treatment differences. Using an
Descriptive statistics and differences between sessions of imagery alpha level of .05, results indicated that the treatment
accounted for 8% of the variance in pain with an
Sessions of imagery Mean7SD t df da
observed power of .19, 4% of the variance in edema with
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First–fifth session 1.7872.22 2.40 8 .80 an observed power of .12, and 5% of the variance of
First–sixth session 3.6772.06 5.34 8 1.78 total ROM with an observed power of .13.
First–seventh session 4.0073.24 3.70 8 1.23 Possible scores for the VMIQ ranged from 24 (highest
First–eighth session 5.2273.49 4.49 8 1.50
First–ninth session 4.2273.73 3.39 8 1.13
imagery ability) to 120 (lowest ability). The range of
o

First–10th session 5.0073.57 4.20 8 1.40 scores for ‘‘watching somebody else’’ was 46–90
First–11th session 5.0073.57 4.20 8 1.40 (mean ¼ 66714.53) and ‘‘doing himself/herself’’ was
th

First–12th session 5.0073.57 4.20 8 1.40 38–78 (mean ¼ 57.89714.24). The vividness of the
Second–sixth session 3.1172.15 4.35 8 1.45 majority of images obtained ‘‘doing himself/herself’’
Second–seventh session 3.4472.40 4.30 8 1.43
Second–eighth session 4.6773.20 4.37 8 1.46
was clear and reasonable.
Au

Second–ninth session 3.6772.78 3.95 8 1.32

Second–10th session 4.4473.84 3.47 8 1.16
Second–11th session 4.4473.84 3.47 8 1.16 4. Discussion
Second–12th session 4.4473.84 3.47 8 1.16
Third–sixth session 3.7874.84 2.34 8 .78
Third–seventh session 4.1174.20 2.94 8 .98
The purpose of this study was to assess the effective-
Third–eighth session 5.3373.91 4.10 8 1.36 ness of treatment and pain-management imagery on
Third–ninth session 4.3374.06 3.20 8 1.07 pain, edema, and ROM of athletes who had an acute
Third–10th session 5.1174.96 3.09 8 1.03 grade II ankle sprain. The results revealed that the
Third–11th session 5.1174.96 3.09 8 1.03 participants in the relaxation and imagery condition did
Third–12th session 5.1174.96 3.09 8 1.03
not have significantly decrease on pain than those in the
a
Effect size; po .05. control condition. In contrast, Cupal and Brewer (2001)
 ARTICLE IN PRESS
136 A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140
Table 2
Means and standard deviations (SD) of pain, edema, and total range of motion between relaxation and imagery and control conditions
Variables Relaxation and imagery
condition
Mean7SD
Pain 177.60743.53
Edema 55.33714.14
Total range of motion 11.5372.08
a
Effect size.
found a positive effect of imagery on pain of athletes
with ACL reconstruction surgery. Similarly, previous
research has shown the positive influence of imagery
treatment on pain reduction (Nicol, 1993; Sthalekar,
1993). Furthermore, other researchers have reported
reduction in pain when imagery has been applied to
other medical conditions (Akerman & Turkoski, 2000;
Baird & Sands, 2004; Walko et al., 1992).
The descriptive statistics, however, indicated a reduc-
tion in pain in the relaxation and imagery condition
(Table 3). In addition, the large effect size points
differences between the two conditions. Although there
were no significant main effects of relaxation and
imagery condition on the five measurements of pain
rs
[F (1, 16) ¼ .00, p ¼ .99; F (1, 16) ¼ .61; p ¼ .45;
F (1, 16) ¼ 1.32, p ¼ .27; F (1, 16) ¼ .35, p ¼ .56], the
pain-management techniques were effective on pain
pe
reduction early in the rehabilitation process, that is, in
the second and third measurement of pain in the
physiotherapy treatment. Moreover, the treatment
effects were large in the second, third and fourth
measurements. This finding is consistent with Ievleva
and Orlick’s (1999) findings that application of pain-
management imagery may be more appropriate soon
r's
after the injury and in the first sessions of the
rehabilitation process. Similarly, Cupal and Brewer
(2001) used pain-management imagery in the first few
sessions of a sport injury recovery period.
o
It is unclear, however, why in this study the pain-
management imagery did not reduce injured athletes’
th
pain to a statistically significant extent. According to
gate control theory of pain, the perception of pain is
blocked, when the impulse transmission is sufficiently
Au
inhibited at the level of the spinal cord. There is a great
risk to report that imagery did not cause inhibition of
impulse transmission; thus reduction of pain. Moreover,
the lower observed power associated with the analyses in
this study showed that it would be not appropriate to
report that imagery can prevent some of the peripheral
pain stimulation from reaching perception. Further
studies should be conducted to clarify if changes in the
central nervous system influence the gate control theory,
and, if so, to examine which specific neurophysiological
mechanism is responsible for the reduction of pain.
Control condition
Mean7SD F df da
214.86743.53 .37 1,16 .86
65.44714.14 .25 1,16 .71
py
9.7372.08 .37 1,16 .52
co
Another question that should be answered in future
research is whether imagery contributes to the release of
endorphins, which diminishes the propagation of pain
transmission.
The present results showed that participants who had
undergone individual sessions of imagery in the phy-
siotherapy program did not show significantly greater
al
reduction on edema and a significantly greater increase
on ROM than those who followed only the physiother-
apy course. As a result, the imagery intervention did not
on
achieve its purpose. Descriptive statistics, however,
indicated a reduction on edema and an increase on
total ROM in the relaxation and imagery condition
(Table 3). Moreover, the medium effect sizes of
treatment point to differences between the two condi-
tions. Why imagery did not reduce edema and increase
ROM of athletes with a ligament injury is a question for
further research. Also, what mechanism takes part in the
recovery outcomes of orthopedic sport injuries should
be examined. Thus, it is important that new research
efforts should be directed to provide additional infor-
mation about imagery and recovery outcomes of a sport
injury using stronger imagery treatments.
A key strength of the current study was the objective
evaluation of sport injury and the recovery outcomes.
All participants had a similar injured ligament of the
ankle, confirmed by ultrasound testing. Previous studies
used participants with different injuries (Brewer, Jeffers,
Petitpas, & Van Raalte, 1994) or did not mention the
type of athletic injury studied (Richardson & Latuda,
1995; Sordoni, Hall, & Forwell, 2000). Also, this study
used reliable and valid methods for the assessment of the
pain, the edema, and the ROM of ankle sprain
(McCulloch & Boyd, 1992; Petersen et al., 1999; Price
et al., 1983; Wilson et al., 1998).
An additional strength of the study is that partici-
pants in the relaxation and imagery condition showed
that they were familiar with imagery techniques, because
they used imagery during their training program.
Examining participants’ imagery ability, they were
instructed on how to perform imagery vividly and
clearly during imagery sessions. Participants increased
their imagery ability at the three first sessions of
imagery, and their imagery ability remained stable and
 ARTICLE IN PRESS
A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140 137

1.43
1.11
1.34
.29
.39
high thereafter, suggesting that the imagery training was
da
successful. The mean score of images for the relaxation
and imagery condition was 31.88 in the manipulation
Signif. level

check (a 40.00 score was the highest possible imagery

.78
ability), thus, the participants showed the ability to
clearly and vividly imagine a movement.
Treatment imagery (i.e., imagining the physiotherapy
4,64

treatment promoting quick and efficient recovery) is one

df

py
of the previously mentioned four types of imagery that
Total range of motion

may be applied during injury rehabilitation (Botterill

.30
F

et al., 1996). This type of imagery did not achieve its

purpose, even though it seemed like a good idea to
17.4473.41
17.4474.29
11.4472.95
6.5671.91
4.7871.49
18.4473.41
15.7874.29
7.2272.95
4.4471.91
2.7871.49
Mean7SD

co
examine on the sport rehabilitation process at the time.
Further research should examine the impact of other
types of imagery on sport rehabilitation process (i.e.,
performance imagery, affirmation imagery, rehabilitation-
1.19

process imagery, and healing imagery). Future experi-

.31
.75

.76
.50
a
d

ments may describe imagery protocols in injury rehabi-

litation adequately, providing information, such as nature
Signif. level

al
and type of instructions, timing of instruction, number
and length of sessions (Morris, Spittle, & Watt, 2005).
.78

Another major limitation of the study is the use of

on
VMIQ which is not a strong measure of internal and
4,64

external imagery. Although, participants in the relaxa-

df

tion and imagery condition increased self-report of

.17

ability to imagine themselves performing various move-

F

rs

ments from an internal perspective and to imagine

102.22725.44
82.22720.39
47.78713.99
27.78710.33

110.00725.43
97.78720.39
64.44713.99
35.56710.33

somebody else performing movements, the change in

16.6775.54

19.4475.54
Interaction effects of ‘‘condition’’ and ‘‘measurements’’ in pain, edema, and total range of motion

Mean7SD

VMIQ scores do not reflect actual use of internal and

pe

external imagery. Future studies should be conducted to

Edema

measure imagery ability with standardized assessment

instruments such as the Sport Imagery Ability Measure
(SIAM; Watt & Morris, 1998) or with valid and reliable
1.10
1.62
.20

.84
.00
a

instruments specific to the sport injury rehabilitation

d

process. Other limitations of this study include the

Signif. level

relatively small overall sample size that made it difficult

r's

to detect significant effects in the measures of rehabilita-

tion and the different sports involved.
.74

Pleasant and neutral imagining are dissociative pain-

management techniques in the imagery intervention that
4,64

o
df

are easy to learn (Heil, 1993) and tend to be effective on

pain reduction (Fernandez & Turk, 1986). These
.28

th
F

strategies did not have a positive influence on sport

injury pain. Additional research should be conducted to
565.577106.35

567.567106.35
187.00772.03
89.89745.66
45.56736.89

266.22772.03
164.00745.66
76.56736.89

confirm these results using other associative (e.g., pain

.007.00

.007.00
Mean7SD

Relaxation and imagery condition.

Au

acknowledging and dramatized coping) and dissociative

(e.g., external focus of attention and rhythmic cognitive
Pain

activity) pain-management techniques (Fernandez &

Turk, 1986; Wack & Turk, 1984).
Measures

Moreover, more experimental intervention strategies

Control condition.

are needed using control and placebo groups as well as

randomization of participants. Without adequate con-
1
2
3
4
5
1
2
3
4
5

Effect size.

trols, which include assessing the impact of potential

Condition

placebo effects, it is difficult to separate treatment effects

Table 3

from effects of other intervening variables (Cupal,

b
a

c
b

1998). Also, using samples that agree to participate in

2c
1
 ARTICLE IN PRESS
138 A. Christakou, Y. Zervas / Physical Therapy in Sport 8 (2007) 130–140
the study may be more motivated to recover, thus
threaten study’s external validity (Cupal, 1998).
Also, in future studies, it would be beneficial to
evaluate pain intensity using other reliable and valid
pain measurement instruments, such as the Present Pain
Intensity Index (PPI; Melzack, 1987). Future researchers
should attempt to use larger sample sizes even though
may be difficult to recruit injured athletes who have the
same demographic characteristics (i.e. dominant limb,
sport, sex, years of training) and type of injury.
Additional research may wish to examine the effect of
imagery on the transmission of sensory pain impulses to
the brain. Lastly, it would be useful to assess the
effectiveness of imagery on other athletic orthopaedic
injuries in different parts of the body (e.g., shoulder).
5. Conclusions
According to our findings, the treatment and pain-
management imagery did not show demonstrable effects
on pain, edema, and ROM in athletes with an ankle
on
sprain grade II. Further research could address the
relationship between different types of imagery and
rehabilitation from sport injury using stronger imagery
treatments, including larger sample sizes, placebo
rs
groups and well-developed imagery instruments adapted
in injury rehabilitation. Future studies also need to
investigate psychophysiological processes associated
with sport injury rehabilitation.
pe
Acknowledgements
We acknowledge financial support from the Alexsan-
dros S. Onasis Scholarships Foundation. Also, we
would like to thank all those who assisted the
r's
completion of this study. Finally, special thanks to the
anonymous reviewers for their helpful suggestions on
the early draft of this manuscript.
o
Ethical Approval
th
Appropriate ethical approval had been granted prior
to the commencement of the study. All participants of
Au
the study were informed about the procedures of the
study and signed a written informed consent form
proposed by the scientific team of the University. In
particular, participants had the right to interrupt their
participation from the study at any time and the
publication of the results must have been anonymous.
Conflict of Interest Statement
None.
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