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Returning to sport after long term injury

process (Podlog & Eklund, 2006). An athlete’s journey back to sport and their response to injury and the rehabilitation process has been investigated by multiple studies (Bianco, Malo, & Orlick, 1999; Podlog, & Eklund, 2007; Weiss, 2003), which have resulted in finding that successfull rehabilitation for an athlete will not only focus on the physical aspects of the rehabilitation process, but will attain to the psychological aspects also (Weiss, 2003) as psychological obstacles such as could avert an athlete from returning to participating fully (Podlog & Eklund, 2005). Several other studies have shown that rehabilitation success and actual return to participation, depends on an athlete’s social support and self motivation (Grindley, & Zizzi, 2005; Kvist, Ek, Sporrstedt, & Good, 2005). Unfortunately, there is a lack of qualitative studies investigating the differences in social support, self motivation and the experiences during the return to sport process of team or individual athletes of varying participation levels who have suffered serious injury.

Shaw, Ostrow and Beckstead (2005) explain that motivation is fundamental to an athlete’s participation in sport, the rehabilitation process following injury and is used to explain the why of individual behaviour. Motivation includes intrinsic motivation, which is based on an individual’s experience accomplishment and knowledge and also extrinsic motivation which is based on identification and regulation. The Self Determination Theory which is proposed by Ryan and Deci (1985) can be used to focus on motivation within athletes and the influences certain behaviours have on the injured athlete during the rehabilitation process (Shaw et al., 2005). The Self Determination Theory (Ryan & Deci, 2000) is an investigation into the basis of self motivation and the integration of personality into inherent growth tendencies of human beings with regard to psychological needs. The Self Determination Theory suggests that there are three innate human needs which facilitate optimal growth and function, these are; Competence (Harter 1978), Relatedness (Baumeister & Leary, 1995) and Autonomy (Deci 1975). The Self Determination Theory suggests that social-contextual factors influence self motivation and that the behaviours individuals perform are not active because of intrinsic motivation alone (Ryan & Deci, 2000). Self Determination theory however explains that differing states of motivation co exists along a continuum of self determination, which includes amotivation, which signifies the lowest form of self determined motivation and intrinsic motivation, which is opposite to amotivation on the scale and signifies the highest form of self determination (Ryan & Deci, 2000).

Behaviour which is motivated extrinsically is what consists within the continuum between amotivation and intrinsic motivation, these include externally regulated motivation, introjected regulation, identified regulation and integrated regulation. Ryan and Deci, (2000) explain that an athlete who will return to sport because of being threatened by replacement if they do not return, is externally regulated. The individual is demonstrating avoidance from consequences of a negative nature or an urge for reward gain. Ryan and Deci (2000) also explain that an individual whose behaviours involve returning to avoid letting down team mates is regulated by introjected motivations to avoid the feelings of guilt or to obtain an enhancement of the ego. Ryan and Deci suggest that within extrinsic motivation, identified motivations are more of a self determined approach, as the behaviour is performed by the individual with personal appraisal and support for the behaviour, for example an athlete returning because of desire to win a tournament of importance. The final type of external motivation on the continuum is integrated regulation which is regulated by integrated motivations and can be characterized by an athlete returning because they love to demonstrate athletic ability.

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It can be expected that when an athlete suffers a serious injury the individual will go through varying stages of mental processes and the individual’s physical state is not attained to alone but the psychological state of the athlete is also considered (Wagman & Khelifa, 1996). The psychological responses to injury can consist of denial, anger, bargaining, depression, and finally acceptance and recognition (Crust, 2010). Wagman and Khelifa, (1996) suggested that an injured athlete can also experience fear as a psychological response to injury. Kvist et al. (2005) support the concept of fear as a psychological response by stating, denial of the injury occurring, a fear of re-injury, fear of an inability to fully recover or fear of losing a place on a team are all fears related to injury with fear of re injury being considered to be the most common amongst athletes who are injured. Linking back to Self determination theory, this can result in decreased self motivation and confidence, as the individual feels a lack of competence (effectively dealing with their environment).

With regards to returning from injury, The Self Determination Theory can be used as a theoretical framework. Findings within the area of competency suggest that athletes do fear re injury, and that performing at the same level as they did pre injury, causes them concern. Bianco et al. (1999) found that athletes who are returning from injury are highly concerned about their body’s ability to perform to the demands of their sport. This would further propose that issues of physical competence may hold significance. Gould, Udry, Bridges and Beck (1997) suggest that the consequential factors of an individual having these fears and frustrations can lead to a decreased perception of self efficacy. Supporting this, Taylor and Taylor (1997) found athletes also undergo competence concerns with regards to future performances and the accomplishment of both external and personal expectations. To further support this concept Vallerand and Reid (1984) who used verbal feedback, intrinsic motivation and perceived competence with a path analysis in relation to the Cognitive Evaluation theory (1984). They found that intrinsic motivation is assisted by social and environmental factors and also that perceived competence influences intrinsic motivation. It could be concluded from this information that during the attempt to make a return to sport, issues of competence may be at the foreground of an athlete’s mind.

Podlog and Eklund (2007) discuss Relatedness issues with regard to The Self Determination theory and suggest that during the process of returning to sport from injury, relatedness may shape to be a leading component to recovery. Feelings of isolation and alienation socially from teammates, competitors and even friends could figure prominent during an injured athlete’s return to sport. This view is supported by Kvist et al. (2005) who found that successful rehabilitation for an athlete can entirely depend on the level of social support that they are provided. Barefield and McCallister (1997) report that there are different types of social support that can be provided to injured athletes. Emotional and listening support regards the awareness from the athlete that others are providing care and listening without expressing judgement. Emotional challenge involves the athlete perceiving their social support to challenge and evaluate their beliefs, feelings and attitudes. Another type of social support is Task challenge, and compared to emotional challenge involves the social support attempting to motivate and lead the support toward the athlete which will lead to the excitement and involvement of the athlete. Task appreciation is another method of social support and involves the athlete perceiving that others acknowledge and express appreciation of their attempts towards tasks. By providing the athlete with the perception that they are supported and have the same outlook and perspective as others, the athlete gains reality confirmation, which is another method of social support. Tangible and personal assistance are also methods of social support. Providing financially with gifts or doing favours/running errands, can also provide an injured athlete with the perception they are gaining support.

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Barefield and McCallister (1997) corroborate the need for an injured athlete’s social support, claiming that enhanced rehabilitation will derive from social support. Social support however is a multidimensional concept, with significant differences between the social support provided by an athletic trainer compared to a head coach or assistant coach (Robbins & Rosenfeld, 2002). It has been found that the support provided by a head/assistant coach is perceived to be less than that of an athletic trainer (Robbins & Rosenfeld, 2002). With social support being a multidimensional concept differing experiences can cause an athlete to isolate themselves from the team and sport, these include; anxiety, fear, tension, loneliness, hostility or confusion (Robbins & Rosenfeld, 2002).

With this research it could be suggested that a team athlete compared to an individual athlete may have an increased chance of better rehabilitation with regards to relatedness as there is the added social implication of a team compared to the single relationships an individual athlete may have with only a coach, training partner or athletic trainer.

Gould et al. (1997) reported that individual US skiers perceived a lack of interest from the coach and training partners which lead to feelings of extreme isolation during the recovery period. The investigation conveyed that the individual athletes felt cut off from their coach and familiar routines, also that maintaining social interaction with training partners was very difficult during the rehabilitation process, leading to a lack of interaction, which linking back to The Self Determination theory can result in a decreased level of relatedness within the athlete. Mainwaring, Krasnow and Kerr (2001) found that an injured dancer will not appreciate some methods of social support, for example a dancer with a severe knee injury will not appreciate a considerate or “disabled” view towards them and when on crutches the individual especially disliked doors being held open for them. Mainwaring et al. (2001) however did not find what a dancer will view as appropriate social support and suggest that social support such as helping the individual adapt their training programme to the medical advice gained from professionals or something as simple as rest may be a better option, this however is not known for certain.

During the injury rehabilitation process a team athlete which stays involved with the team could be assisted during the process from injury to training to competition. It is suggested that injured team athletes could miss out on the social aspect of their participation within the sport (Podlog & Eklund, 2004).

Ensuring that the injured individual continually stays in contact with the team through their injury can provide the athlete with a sense of connectedness and provide them with the opportunity to observe, learn and analyse their sport form the sidelines. Taking the sport in from the view of an observer could help the athlete come to certain realisations and understandings about important aspects of successful performance which they can incorporate on their return, and relating back to The Self

Determination theory further help with the athletes perception of autonomy. Spending time with teammates and peers is regarded by many as crucial to the rehabilitation period (Bianco 2001, Podlog & Eklund 2004) but Mainwaring et al. (2001) stress that merely observing classes, rehearsals or training is not enough and the injured athlete requires involvement in events also to feel an adequate level of relatedness.

In conclusion it can be said that after suffering a serious injury the journey of returning to sport for an athlete, can be a difficult and a demanding process (Podlog & Eklund, 2006) and possibly team and individual athletes may have different responses to social support, which could further effect their motivation in returning to their sport during the return to sport process. Unfortunately, there is a lack of qualitative studies investigating the differences in social support, self motivation and the experiences during the return to sport process of team or individual athletes of varying participation levels of either elite or sub elite. The aim of this study is to investigate the motivation of the team or individual athlete who performs at either elite or sub elite level during the return to sport process after a serious injury. It is hypothesised that team athletes and elite performers will be higher inclined to return to sport because of the added social implication of a team and an elite performer being institutionalised into their sport.

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Participants

The participants of this research study will be male athletes between the ages of 20 and 25 years. The sample size for this study will be 4. The team athletes are individuals who have a background playing rugby, one participant has performed at international level and is at a professional club, the other participant performs at a social club level ; the individual athletes have a background participating in Judo at international level and Triple Jump in Athletics. The individuals will be recruited through convenience sampling and purposive sampling techniques. Inclusion criterion is that you must be a team/individual performer of either an elite or sub elite standard and be returning from injury. Previous research (Bianco, 2001) suggests that a serious injury can be quantified as the participant being absent from participation in sport for at least 2 months. Bias has to be considered as the individuals who are being interviewed as team participants are team mates of the researcher from St Mary’s Rugby League team. To reduce bias bracketing and pilot interviews will be conducted prior to the investigation commencing.

Measures

An interview guide which will consist of the questions asked to participants will be created based on the review of literature, previous research into the return to sport process and transition following serious injury (Podlog & Eklund, 2007). The questions are designed to extract information regarding the athlete’s perception of their return to sport process following injury and the perception of their social support during this process. The interview guide will be examined through bracketing interviews, pilot testing and questions will be refined before athletes participate in the investigation to ensure a reduction in bias. A pilot will be conducted to test and develop the sufficiency of research instruments and protocol, help identify any problems which may arise using the proposed method and data analysis techniques. Bracketing will be used as a method to diminish the potential of preconceptions within the qualitative approach. Preconceptions can have a detrimental effect which could potentially taint the research process.

Procedures

An informed consent procedure will be conducted at the start of the interview. The participant will agree to participate in the interview and sign a consent form prior to answering any questions. The interview will be tape recorded using a Dictaphone and last between 30-60 minutes. The interview will be conducted in a setting which the participant feels comfortable to discuss and reflect on their experiences during the return to sport process following serious injury openly.

A semi structured interview format will be used to allow participants to discuss specific themes and issues, while the order of the interview can remain flexible. This will allow the interviewer to gain rapport with the participant and ensure the interview has a conversational tone. Where appropriate, probe questions such as ‘What do you mean by…’ ‘How do you feel when…’ will be used to explore answers and gain greater depth and clarity from interview answers.

Data Analysis

Audio recordings of the 4 interview transcripts will be transcribed. The identification of key themes within each interview (intratextually) and across interviews (intertextually) will be conducted.

Intratexual analysis of the data gained from interviews will involve the appointment of text segments into theme categories, e.g quotes which are relevant to the research questions. This process will be carried out inductively until all the text segments have been grouped into theme categories. An inductive approach is being used to allow the researcher take the open ended question and make constant comparisons and potentially work towards a conclusion. Even though the conclusion is likely to be based on a premise and involve a degree of uncertainty, an inductive approach will allow the researcher to investigate the observations made and build an idea. Intertexual analysis will also occur. Comparison of ideas, quotes and themes across interviews will take place. A comparison of participant responses across interviews with regard to interview questions will also occur. To ensure trustworthiness in the data an independent individual from the investigation (Dr Anne-Marie Knowles) will conduct an independent audit and an independent categorisation of themes drawn from the interviews. The data will be organised into a research report so that a chain of evidence can be followed also. Confirmability will be ensured by the use of quotes in the results section to confirm what has been said. Along with this method of confirmability, member checking will also be used.

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