THE LEVEL OF MENTAL IMAGERY USE BY INJURED COLLEGIATE ATHLETES
DURING REHABILITATION

A THESIS
Submitted to the Faculty of the
School of Graduate Studies and Research of
California University of Pennsylvania in partial fulfillment
of the requirements for the degree of
Master of Science

By
Brandon F. McClendon

Research Advisor, Dr. Thomas Kinsey
California, Pennsylvania
2009

ii

iii

ACKNOWLEDGEMENTS
I would like to take this opportunity to acknowledge
all those who played a big part in the completion of this
project.

I would not have been able to complete my thesis

without your assistance.
First, I would like to acknowledge my committee
members, Dr. Tom Kinsey, Dr. Taunya Tinsley and Dr. Ayanna
Lyles.

Thank you for keeping me on track and making sure

this project turned out to be something worth reading.

I

really appreciate all of your help these past two semesters
and again I wouldn’t be in the position I am in without
your assistance.

Thank you for sticking when it seemed as

though I would never finish this study.
Next I would like to acknowledge Dr. Craig C. Hall of
the University of Western Ontario for allowing me access to
the Athletic Injury Imagery Questionnaire-2 (AIIQ-2).
instrument played a large part in my study.

This

Thanks again

for your help; your assistance was greatly appreciated.
Another faculty member of California University of
Pennsylvania I would like to acknowledge is Dr. Chris
Harman.

Dr. Harman kept me on track with my Institutional

Review Board requirements and made sure I had everything in
order before submitting it for approval.

She was always

iv
supportive even when I was behind; she made sure I was
still working towards completing the study.
Another person that played a big part in making this
paper better is Ms. Dorothy Ingram.

She took the time out

of here busy schedule and helped me edit my final draft
several times.

I really appreciate you taking the time to

read my paper, word for word, making suggestion to improve
its quality.

Without your help I would have continued

reading what it meant to say not what was actually on the
paper.

To anyone looking for an editor, I highly

recommended Ms Dorothy Ingram!

Thanks again!

Next, I would like to acknowledge the Graduate
Athletic Training Class of ’09 of California University of
Pennsylvania.

You guys are amazing.

Thank you for all of

your help with all the odds & ends of writing a thesis.
Good luck in the future.

In the words of mister Vince

Lombardi, “Perfection is unattainable, however if we strive
for perfection we can reach excellence.”
Furthermore, I would like to acknowledge California
University of Pennsylvania and its Athletic Training Staff.
Thank you for allowing me to work with your athletes.

I

didn’t have many interactions with a lot of you but thank
you for coming through for me when I was looking for
subjects.

v
And finally I would like the acknowledge my little
lady, Ms. Aleah Alice McClendon, for providing me with the
necessary inspiration to keep working on the project even
when I was beginning to get discouraged.

I Love You.

I

was a lot of fun, and a little challenging, trying to feed
you a bottle while trying to analyze data and write a
discussion.

vi
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
LIST OF TABLES
INTRODUCTION

. . . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . . 1

METHODS. . . . . . . . . . . . . . . . . . . 11
Research Design
Subjects

. . . . . . . . . . . . . . 11

. . . . . . . . . . . . . . . . . 11

Instruments . . . . . . . . . . . . . . . . 12
Procedures

. . . . . . . . . . . . . . . . 13

Research Questions
Hypotheses

. . . . . . . . . . . . . . . . 14

Data Analysis
RESULTS

. . . . . . . . . . . . . 14

. . . . . . . . . . . . . . . 15

. . . . . . . . . . . . . . . . . . 16

Demographic Data . . . . . . . . . . . . . . 16
Hypothesis Testing

. . . . . . . . . . . . . 21

Additional Findings . . . . . . . . . . . . . 25
DISCUSSION . . . . . . . . . . . . . . . . . 27
Additional Findings . . . . . . . . . . . . . 29
Recommendations for Future Research

. . . . . . 31

Professional Training Implications . . . . . . . 33
Clinical Implications . . . . . . . . . . . . 35
Conclusions . . . . . . . . . . . . . . . . 36

vii
REFERENCES . . . . . . . . . . . . . . . . . 38
APPENDICES. . . . . . . . . . . . . . . . . . 46
APPENDIX A: Review of Literature

. . . . . . . . 47

Introduction . . . . . . . . . . . . . . . . 48
Injuries

. . . . . . . . . . . . . . . . . 48

Athletic Trainer . . . . . . . . . . . . . . 50
College Athletes . . . . . . . . . . . . . . 53
Intervention Methods

. . . . . . . . . . . . 56

Mental Imagery . . . . . . . . . . . . . . . 57
Summary . . . . . . . . . . . . . . . . . . 70
APPENDIX B: The Problem . . . . . . . . . . . . 73
Problem Statement . . . . . . . . . . . . . . 74
Definition of terms . . . . . . . . . . . . . 74
Basic Assumptions . . . . . . . . . . . . . . 75
Limitations of the Study . . . . . . . . . . . 75
Significance of the Study

. . . . . . . . . . 76

APPENDIX C: Additional Methods . . . . . . . . . 77
Informed Consent Form (C1) . . . . . . . . . . 78
Student Athlete Response Sheet (C2)

. . . . . . 80

IRB: California University of Pennsylvania (C3).
Athletic Director Consent Form (C4)
References
ABSTRACT

. 83

. . . . . . 90

. . . . . . . . . . . . . . . . 92
. . . . . . . . . . . . . . . . . 100

viii

LIST OF TABLES
Table

Title

Page

1

Frequency Table By Sport

17

2

Frequency table by Reported Injury

18

3

Frequency table of reported Severity
of Injury

19

4

Frequency Table for Formal Mental
Imagery Training

20

5

Mean and Standard Deviation for each
item on the AIIQ-2

21

6

Descriptive Statistics

22

7

Pearson Correlation

22

1

INTRODUCTION

The mind and body are physically connected however in
some cases they are viewed as separate entities.

“Mind

over matter” is a statement often used to get through tough
situations (Morgan, 1984).

Mental imagery is a technique

used to focus the mind on a particular task or event (Cox,
2001).

Mental imagery is defined as using all the senses

to create or re-create an experience in the mind without
the external stimuli (Cox, 2001).

The image is created

using information stored in the information register,
working memory, or long term memory (Cox, 2001).

According

to Cox (2001) mental imagery has many uses in athletics.
Athletes can use mental imagery to practice skills, to cope
with stressful situation, and for pain management.
The sub-categories of imagery are motivational
imagery, cognitive imagery, and healing imagery
Motivational imagery is the use of mental imagery to
experience goal attainment, effective coping, and/or
arousal management.

Cognitive imagery is the use of mental

imagery to experience specific sports skills and to plan
strategies before during and after competition (Cox, 2001).

2
Healing imagery is the use of mental imagery to visualize
the healing process (i.e. tendons reconnecting to bones).
Psychological antecedents and emotional reactions play
a key role in athletic injury rehabilitation.

Herring,

Boyahian-O’Neill, Coppel, Daniels, Gould, Grana et al.
(2002) reported that the use of psychological strategies
such as goal setting, positive self-talk, cognitive
restructuring and imagery techniques are associated with
faster recovery.

Thus these strategies could have an

effect in reducing the length of rehabilitation and
shortening the time that an athlete is not participating in
his/her sport.

Athletic Trainer
Athletic trainers are allied health care professionals
recognized by the American Medical Association, who
collaborate with physicians to optimize activity and
participation of physically active patients and clients.
The typical athletic training setting includes:
professional sports, collegiate athletic, high school
athletics, sports medicine clinics, as well as health/
fitness clinics.

Athletic training encompasses the

prevention, diagnosis, and intervention of emergency,
acute, and chronic medical conditions of athletic injuries.

3
These conditions may include physical impairments,
functional limitations, and disabilities (National Athletic
Trainers’ Association [NATA], 2009).
Athletic trainers typically spend extended periods of
time with athletes under conditions that promote personal
interactions and trust (Moultan, Molstad, & Turner, 1997).
Each of the six domains of the athletic training profession
has psychological competencies associated with them.
The domains of athletic training are: (1) the
prevention of athletic injury and conditions, (2) clinical
evaluation and diagnosis of athletic injury conditions, (3)
the immediate care of athletic injuries and conditions, (4)
treatment rehabilitation and recognition of athletic
conditions, (5) organization and administrative duties, and
(6) professional responsibilities for the profession (NATA,
2009).
The Competencies provide educational program personnel
with the knowledge and skills to be mastered by students in
an entry-level athletic training educational program.

The

competencies include recognizing the psychological signs
and symptoms of athletic injury, practicing effective
communication skills in the areas of health maintenance,
and provide athletes with injury prevention education in
relation to athletic injury.

It is the ethical duty of

4
athletic trainers to recognize problems within the realm of
our training and competencies and refer those that are not.

Collegiate Athletes
The college student athlete can present to the
athletic trainers, sport psychologist, educators, sports
counselors, and other helping professionals with the same
developmental issues non-athletes face (Fletcher, Benshoff,
& Richburg, 2003).

These issues may include the cognitive,

social, moral, educational and psychosocial development of
the student athlete during their collegiate years (Fletcher
et al., 2003).

Furthermore, the college student athlete is

also developing their independence and establishing their
sense of self.

Fletcher et al., (2003) stated that an

athlete’s success on the field was linked to their overall
development and emotional well-being.

If an athlete is

unsuccessful on the playing field, he/she may become less
motivated to continue going to practice.
Based on the literature, college students face a great
deal of stress in their daily life as students (Fletcher et
al., 2003).

College is the setting where students make an

attempt to establish themselves as an individual separate
from their parents (Fletcher et al., 2003).

College

student athletes, on the other hand, deal with the stress

5
of effectively balancing their role of being a student, an
athlete, and developing their sense of self (Tinsley,
2005).

Identity foreclosure happens when an athlete

relates his/her identity as a person to their identity in
athletics.

Murphy, Petitpas, and Brewer (1996) stated that

the belief that a narrow focus on sport is necessary for
competitive success may be held by student athletes and
strongly reinforced by coaches.

As a result coaches and

administrator may become less likely to support external
activities that may distract their athletes from their
sport (Murphy et al., 1996).
Athletes at all level face the fear of losing their
playing status (Petrie, 1993).

Some players are able to

handle this pressure while others are not able to.

The

athletes’ playing status is the role he/she is has on the
team.

Their role could be starter, second string, relief

pitcher etc.

There are multiple ways an athlete can alter

his/her playing status.

Injury, poor performance, and

retirement are a couple instances where the athlete’s
playing status may be altered.

Developing a sound set of

coping skills can help athletes deal with the pressure of
balancing their multiple roles.

These roles include

consistently performing at a high level in their sport and
academic career, as well as developing their sense of self.

6
Mental Imagery
Mental imagery is one technique adopted by athletes to
manage fear as well as improve performance and selfconfidence (Chase, Magyar, & Drake, 2005).

These

techniques are often implemented by athletic trainers,
sport psychologists, as well as counselors.

Mental imagery

can also be used to help with pain management and pain
tolerance.

The client could use mental imagery skills

decrease anxiety associated with the injury which could
decrease their perception of pain.
Chase, Magyar, and Drake (2005) study, which focused
on fear of injury and self efficacy, interviewed 10
gymnasts ages 12-17.

All participants in the study were

from the Midwest and competed at level 7-10.

These

subjects had a training age of approx 8.7 years.

In this

study the gymnasts were asked questions about the types of
injuries in gymnastics, reasons they participate, their
fear of injury, sources of self efficacy (self-confidence)
and mental/physical strategies used to overcome fear of
injury.
A person’s self efficacy may help them overcome the
fear of injury.

According to Bandura (1997) self efficacy

is a person’s beliefs in his or her own capabilities.
There are four factors known to affect ones self-efficacy:

7
performance accomplishments, vicarious experience, verbal
persuasion, and physiological arousal.

In order to conquer

the fear of injury, athletes must learn skills in order to
manage the fear.
One function of mental imagery in athletics is pain
management.

Law, Driediger, Hall & Farwell (2006) used the

Athletic Injury Imagery Questionaire-2 in conjunction with
the Visual Analogue Scale (VAS) for pain and the Lower
Extremity Functional Scale (LEFS) to examine the
relationship between the athletes’ imagery use and their
perceived pain levels.

The VAS for pain is a ranking

system that allows the client to give a visual
representation of their pain level.

A typical item in a

VAS is a line with marked with the values zero through ten.
The client places a mark on the line that represents
his/her current pain level.

The LEFS is a series of tests

used the check client’s ability to perform certain
movements with the leg.

These questionnaires were used to

determine whether athletes who used imagery for pain
management employed more cognitive, motivational, and
healing imagery than the athletes did not (Law et al.,
2006).
Law et al. (2006) further states that athletes who
employed imagery to alleviate pain were more satisfied with

8
their rehabilitation than athletes who did not use imagery
to manage pain.

Athletes often experience pain during

different phases of the rehabilitation program.

The

purpose of the early phase of rehabilitation is it to
control pain and the other initial signs of inflammation
(Prentice, 2005).
Moreover, Law et al. (2006) report that mental imagery
should be used by injured athletes to manage pain; however
these results do not translate to improved functionality or
changes in the athletes’ degree of pain.

Law et al. (2006)

does emphasize that imagery during rehabilitation did
increase the athletes’ satisfaction with the rehabilitation
program.
Another important use for mental imagery is pain
tolerance.

Syrjala, Donaldson, Davis, Kippes, & Carr

(1995) used 94 patients that have been diagnosed with
cancer.

Each of the participants recently had or were

preparing for their first bone marrow transplantation
(BMT).

The purpose of this study was to test the oral pain

level among the following intervention groups.

The

interventions associated with the Syrjala et al., (1995)
study are treatment as usual (TAU), therapist support (TS),
relaxation and imagery(R&I), and cognitive behavior skills
training (CB).

9
The Syrjala et al. (1995) study reported that both the
cognitive behavior training (p=.0071) and the relaxation
and imagery groups (p=.0088) experienced a reduced pain
level from their BMT.

An analysis of the patients’

perceptions of the helpfulness of the treatments for coping
with the symptoms confirmed by decrease in pain and nausea
levels.

Problem Statement
The literature base of psychological factors
associated with injury is vast; however, there are few
studies that examine the correlation between the use of
these psychological interventions and the length of time
the athletes are enrolled in a rehabilitation program.

The

psychological response to injury can lead to further injury
or an extended rehabilitation.

The mental imagery

techniques discussed in this study can be implemented to
help athletes deal with the stressors associated with
injury and injury rehabilitation.

There is limited

literature that examines correlation between the length of
rehabilitation and use of psychological interventions is
limited.

This study will serve the purpose of expanding

the available literature on psychological skills and their
functions as they relate to athletic training.

10
Research Questions
This study will attempt to answer the following
questions:

1) does severity of injury correlate to the

increased use of mental imagery use during injury
rehabilitation?

2) Does length of rehabilitation correlate

to the increase use of imagery used during athletic injury
rehabilitation?
Research Hypotheses
The following hypotheses were based on previous
research and the researcher’s intuition based on the review
of literature.
1. Athletes with a higher rating for severity of injury
will have a higher score for Cognitive Imagery.
2. Athletes with a higher rating for severity of injury
will have a higher score for Healing Imagery.
3. Athletes with a higher rating for severity of injury
will have a higher score for Motivational Imagery.
4. Athletes with a shorter Rehabilitation of injury will
have a higher score for Cognitive Imagery.
5. Athletes with a shorter Rehabilitation of injury will
have a higher score for Healing Imagery.
6. Athletes with a shorter Rehabilitation of injury will
have a higher score for Motivational Imagery.

11

METHODS

The purpose of this study was to examine the level of
mental imagery use by injured athletes during
rehabilitation.

This section includes the Research Design,

Subjects, Instruments, Procedures, Hypothesis, and Data
Analysis.

Research Design
This research is a descriptive study.

The first set

of variables is severity of injury and length of
rehabilitation in weeks.

The second set of variables

includes the motivational, cognitive, and the Healing
imagery scores.

There was a test for correlation between

severity of injury and all the imagery scores.
Additionally length of rehabilitation and all three imagery
types was correlated.

Subjects
The participants of this study were California
University of Pennsylvania (CALU) student athletes
currently going through rehabilitation for injuries.
Participation was strictly voluntary.

12
Instruments
Athletic Injury Imagery Questionnaire-2 is comprised
of 12 items concerned with the injured athlete’s current
use of imagery.

Items are representative of the three

functions of imagery: motivational imagery (MI), cognitive
imagery (CI), and healing imagery (HI).

Items 3, 5, 9, and

12 are Motivational Imagery items; items 2, 6, 7 and 10
Cognitive Imagery items; and items 1, 4, 8 and 11 are
Healing Imagery items.

According to Sordoni, Hall, and

Forwell (2002), the creators if the AIIQ-2, the reliability
coefficient for the three subsections motivational= .82,
cognitive=.84, and healing=.91.

(Sordoni et al., 2002)

The American Sports Data Sports Injury Report (2006)
has released levels of injury.

Level 1 Injury did not

interfere with subsequent participation.

Level II- Injury

prevented participation on at least one or more future
occasions, but for less than a month.

Level III- Injury

prevented participation for at least a month.

Level IV-

Injury prevented participation for at least a month and
resulted in emergency room treatment, overnight hospital
stay, surgery and/or ongoing physical therapy.

The

demographic sheet will have a section that will allow the
participant to select their injury severity (Lauer, 2006).

13
Procedures
After attaining approval from the Institutional Review
Board participants were selected based on their injury
status at California University of Pennsylvania.
Permission to use CALU athletes was received from the CALU
Athletic Director.
The CALU Athletic Training Staff was contacted by the
researcher via email to determine the status of their
athletic teams and if they had athletes were enrolled in
rehabilitation program.

If they had eligible athletes, the

athletic trainer was contacted a second time in order to
establish a time that the researcher could meet with the
athletes.

The CALU athletic training staff sent a follow

up email to the researcher to identify the potential
subjects that are under their care.

Both in season and out

of season athletes were included in the study.
The questionnaire packet given to participants
consisted of an informed consent document, a demographic
sheet that had the athletes’ sport, years of participation,
injury, severity of injury, and length of rehabilitation.
The last page of the packet is the AIIQ-2 questionnaire.
There is a copy of the questionnaire packet Appendix C.
As an incentive, two subway gift cards were raffled
off after all data was collected.

The participants were

14
issued a raffle ticket upon completing the survey.

The

raffle ticket stub had the participants email address.
winners were contacted via email.

The

This process was

completed separate from the data collection to ensure that
confidentiality was not breached.

Research Questions
1. Does severity of injury correlate to the increased use
of mental imagery use during injury rehabilitation?
2. Does length of rehabilitation correlate the increase
use of imagery used during athletic injury
rehabilitation?

Hypotheses
The following hypotheses were based on previous
research and the researcher’s intuition based on the review
of literature.
1. Athletes with higher rating for severity of injury
will have a higher score for Cognitive Imagery.
2. Athletes with higher rating for severity of injury
will have a higher score for Healing Imagery.
3. Athletes with higher rating for severity of injury
will have a higher score for Motivational Imagery.
4. Athletes with shorter Rehabilitation of injury will
have a higher score for Cognitive Imagery.
5. Athletes with shorter Rehabilitation of injury will
have a higher score for Healing Imagery.

15
6. Athletes with shorter Rehabilitation of injury will
have a higher score for Motivational Imagery.

Data Analysis
SPSS 16.0 was used to test analyzed use for a Pearson
Correlation.

The correlation between severity of injury

and the three types of imagery (Cognitive, Healing, &
Motivation) was tested.

The correlation between length of

rehabilitation and the three types of imagery (Cognitive,
healing and Motivational) were tested.

16

RESULTS

Demographic Data

A sample of the injured athletic population was
surveyed resulting in the following data.

This sample

represents 11 California University of Pennsylvania (CALU)
sport teams (See Table 1).

Forty-one surveys were

administered, and forty were returned.

The sample

represented both in season and out of season sports.

The

average years of participation at CALU were 2.1(SD=1.08).
The average length of rehabilitation reported by the
athletes was 15.3(SD=20.90) weeks.

All information

received was self-reported.
Table 1 represents the sports that the participants
were enrolled in.

Twenty-five percent of the participants

were softball players and a combined Thirty percent were
baseball and softball players.

Rugby, Dance, and Ice

hockey only had one participant from each of those teams.

17
Table 1. Frequency table by Sport
Sport
Number
Softball
10
Baseball
6
Track & Field
6
Football
4
Volleyball
4
M. Soccer
3
W. Soccer
3
Basketball
1
Dance
1
Ice hockey
1
Rugby
1

Percent
25.0
15.0
15.0
10.0
10.0
7.5
7.5
2.5
2.5
2.5
2.5

Table 2 represents the self-reported injury from the
athletes.

Shoulder capsular tightness (4), sprained ankle

(4), and torn labrum were at the top of the frequency
table.

Strained quadriceps (1), strained tibialis anterior

(1), and vertebral disc dislocation (1) were at the bottom
of the frequency table.

18

Table 2.

Frequency table by reported injury

Reported Injury

Number

Percent

Shoulder Capsular
Tightness
Sprained Ankle
Torn Labrum
Hand Injury
Low Back Pain
Pulled Hamstring
Shin Splints
Shoulder Impingement
Shoulder Strain
Back Pain
Biceps Tendon Rupture
Chondromalasia Patella
Elbow Pain
Herniated Vertebral
Disc
Knee Capsulitis
Lateral Petalla
Dislocation
Plantar Fasciitis
Shoulder pain
SLAP Lesion
Spondy
Sprained ACL
Sprained PCL
Strained IT Band
Strained Quadriceps
Strained Tibialis
Anterior
Vertebral Disc
Dislocation

4

10.0

4
3
2
2
2
2
2
2
1
1
1
1
1

10.0
7.5
5.0
5.0
5.0
5.0
5.0
5.0
2.5
2.5
2.5
2.5
2.5

1
1

2.5
2.5

1
1
1
1
1
1
1
1
1

2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5
2.5

1

2.5

19
Table 3 represents the reported severity on injury
based on the American Sport Data Sports Injury Report.
Level 1 represented an injury that did not interfere with
subsequent performance.

Level 2 represented an injury that

prevented participation on at least one or more future
occasions, but did for lest that a month.

Level 3

represented an injury that prevented participation for at
least a month.

Level 4 represented an injury that

prevented participation for at least a month and resulted
in an emergency room visit, overnight hospital stay,
surgery and/or ongoing physical therapy.
Table
Level
Level
Level
Level
Level

3.
1
2
3
4

Frequency table of reported Severity of Injury
Frequency
Percent
14
35.8
13
33.3
4
10.2
8
20.5

Table 4 represents the frequency of the athletes that
have received formal mental imagery training.

Formal

mental imagery was defined in this study as any interaction
between a sport medicine professional (i.e. athletic
trainers, sport psychologist, sport therapist, physical
therapist, or sports counselor) with the purpose of
teaching skills that the athlete can use to cope with
psychological issues associated with injury and injury
rehabilitation.

This definition was not shared with the

20
subjects prior to administering the instrument (see
recommendations for future research).
Table 4.
Training
Response
Yes
No

Frequency table for Formal Mental Imagery
Frequency
4
36

Percent
10
90

Table 5 represents the mean and standard deviation of
each item of the questionnaire.

The twelve items on the

AIIQ-2 were divided in to three sub-categories.
Motivational imagery was represented by items 3, 5, 9, &
12.

Cognitive imagery was represented by items 2, 6, 7, &

10.

Healing imagery was represented by items 1, 4, 8, &

11.

The AIIQ-2 is located in APPENDIX C2.

21

Table 5. Mean and Standard Deviation of each item on the
AIIQ-2
Motivational
Mean
Std Dev
3
5.8
2.59
5
7.1
1.68
9
7.4
2.32
12
5.9
2.73
Cognitive
Mean
Std Dev
2
6.5
2.30
6
5.1
2.73
7
5.3
2.69
10
5.7
2.70
Healing
Mean
Std Dev
1
5.2
3.07
4
5.5
2.84
8
5.6
2.78
11
4.7
2.85

Hypothesis Testing

The section includes the descriptive statistics,
Pearson correlation, hypothesis testing, and the additional
results.
Table 6 represents the descriptive statistics of the
reported items on in the questionnaire packet.
for severity of injury was 2.5 SD=1.15.
rehabilitation was 15.35 SD = 20.92.

The mean

The mean length of

The mean for

cognitive imagery was 22.55 with SD=8.15.

The mean for

motivation imagery was 26.32 SD 7.64. The mean for healing
imagery was 20.55 SD=9.29 (See table 6).

22

Table 6.

Descriptive Statistics

Severity of Injury
Length of Rehab
Cognitive Imagery
Motivational Imagery
Healing Imagery

Mean
2.15
15.35
22.55
26.32
20.55

Std Deviation
1.12
20.92
8.15
7.64
9.29

N
40
40
40
40
40

Table 7 represents the Pearson correlations and their
significance level for all variables.

The table also

represents all the hypotheses testing.
Table 7.

Pearson Correlation

Severity Rehab
Severity Pearson Correlation
1.000
Sig. (2-tailed)

MI

CI

Rehab

Pearson Correlation
Sig. (2-tailed)

0.133
.413

MI

Pearson Correlation
Sig. (2-tailed)

.156
.338

-.085 1.000
.602

CI

Pearson Correlation
Sig. (2-tailed)

-.215
.182

-.014 .714*
.933 .000

1.000

HI

Pearson Correlation
Sig. (2-tailed)

-.225
.165

-.081 .655*
.618 .000

.631*
.000

*.

HI

1.000

1.000

Correlation is significant at the .01 level (2-tailed)

Hypothesis One: Athletes with higher rating for severity of
injury will have a higher score for Cognitive Imagery.
A Pearson correlation coefficient was calculated
examining the relationship between participants’ severity
of injury and cognitive imagery sub-score.

A weak

23
correlation that was not significant was found (r (38) =
.215, p> .05).

This indicates that severity of injury was

not related to cognitive imagery score (see table 7).

Hypothesis Two: Athletes with higher rating for severity of
injury will have a higher score for Healing Imagery.
A Pearson correlation coefficient was calculated
examining the relationship between participants’ severity
of injury and healing imagery sub-score.

A weak

correlation that was not significant was found (r (38) =
.225, p> .05).

This indicates that severity of injury was

not related to healing imagery score (see Table 7).

Hypothesis Three: Athletes with higher rating for severity
of injury will have a higher score for Motivational
Imagery.
A Pearson correlation coefficient was calculated
examining the relationship between participants’ severity
of injury and cognitive imagery sub-score.

A weak

correlation that was not significant was found (r (38) =
.159, p> .05).

This indicates that severity of injury was

not related to motivational imagery score (see Table 7).

24
Hypothesis Four: Athletes with shorter Rehabilitation of
injury will have a higher score for Cognitive Imagery.
A Pearson correlation coefficient was calculated
examining the relationship between participants’ length of
rehabilitation and cognitive imagery sub-score.

A weak

correlation that was not significant was found (r (38) =
.014, p> .05).

This indicates that length of

rehabilitation is not related to cognitive imagery score
(see Table 7).

Hypothesis Five: Athletes with shorter Rehabilitation of
injury will have a higher score for Healing Imagery.
A Pearson correlation coefficient was calculated
examining the relationship between participants’ length of
rehabilitation and healing imagery sub-score.

A weak

correlation that was not significant was found (r (38) =
.081, p> .05).

This indicates that length of

rehabilitation is not related to healing imagery score (see
Table 7).

Hypothesis Six: Athletes with shorter Rehabilitation of
injury will have a higher score for Motivational Imagery.
A Pearson correlation coefficient was calculated
examining the relationship between participants’ length of

25
rehabilitation and motivational imagery sub-score.

A weak

correlation that was not significant was found (r (38) =
.085, p> .05).

This indicates that length of

rehabilitation is not related to motivational imagery score
(see Table 7).

Additional Findings

While testing the hypotheses it was found that the
there was the significant correlation between the use of
motivational imagery and the use of cognitive imagery and
healing image.
A Person correlation coefficient was calculated
examining the relationship between motivational imagery and
cognitive imagery.

A strong significant correlation was

found (r (38) = .714, p< .01)
A Person correlation coefficient was calculated
examining the relationship between motivational imagery and
healing imagery.

A strong significant correlation was

found (r (38) = .655, p< .01)
A Person correlation coefficient was calculated
examining the relationship between cognitive imagery and
healing imagery.

A strong significant correlation was

found (r (38) = .631, p< .01)

26
Additionally a weak correlation was found between the
use reported injury severity and the reported length of
rehabilitation.

A Pearson correlation coefficient was

calculated examining the relationship between severity of
injury and the length of rehabilitation.

A weak

correlation that was not significant was found (r (38)
=.133, p> .05)

27

DISCUSSION

The purpose of this study was to determine if there
was a relationship amongst the severity of an athletic
injury, length of its rehabilitation, and the use of the
three sub-categories of mental imagery.

The first purpose

of this study was to examine length of rehabilitation as it
relates to the use of mental imagery.

The second purpose

was to examine the severity of an injury as it relates to
the use of mental imagery.

This section will include the

discussion of results, recommendations, and conclusion.
Discussion of Results
The researcher’s first set of hypotheses stated that a
higher rating the severity of their injury would relate to
a higher score for motivational, cognitive, and healing
imagery respectively.

There was a weak correlation between

the severity of injury and the use of cognitive,
motivational, and healing imagery.

The results of this

study though not significant did not reflect the literature
on the effectiveness of mental imagery use during
rehabilitation.

Hamson-Utley and Vazquez (2008) suggested

that mental imagery can be implemented with injured
athletes during rehabilitation: to promote healing, to

28
control stress, and to promote and maintain positive mind
set.

The findings of the Hamson-Utley and Vazquez study

can be used as evidence to show that there are benefits of
mental imagery.
Ievleva and Orlick (1991) found that fast-healing
athletes used more goal setting, positive self, and healing
imagery that than slow-healing athletes.

These three

aspects of the Ievleva and Orlick study are valuable tools
for athletic trainers.

A possible reason for the results

that were not significant is this study is the concept of
socially desirable responding.

Athletes may change the

information that they record because they want to be viewed
in a certain way.

Athletes may not want to be seen as

injured: and therefore may not have been honest about the
severity of their injury.

Athletes may not want be honest

about the severity of their injury, because it poses a
threat to their playing status and self concept.
In the second set of hypotheses, the researcher
believed that longer rehabilitation would relate to a lower
reported use of motivational, cognitive, and healing
imagery.

There was a weak correlation between the length

of rehabilitation and the use of motivation, cognitive, and
healing imagery.

The findings of this study, though not

significant, appear to contradict those found in previous

29
studies on effectiveness of mental imagery use.

Driediger

et al. (2006) reported that athletes undergoing
rehabilitation described using imagery before or during
their rehabilitation session as opposed to after.
Sordoni, Hall, and Forwell (2002) completed a very
similar study that used participants with ages ranging from
18-65.

The purpose of the current study differs from the

Sordoni et al. (2002) study in that it is not including
self-efficacy as it relates to mental imagery.

Instead,

the current study focuses on the length of rehabilitation
and the severity of the injury.

Additional Findings
While testing the hypotheses it was found there was a
significant correlation between the uses all three types of
mental imagery (see Table 7).

The athletes in this study

that used motivational imagery were more likely to use
cognitive and healing imagery as well, which is evidenced
by the significant correlation between the three imagery
sub-scores.

These findings support the internal

consistency of the Athletic Imagery Injury Questionnaire-2.
Ten percent of the population (n=4) of the athletes
reported they had formal training in mental imagery (see
Table 4).

Whether or not the other ninety percent (n=36)

30
of the athletes have had some type of instruction on the
use of mental imagery and were unaware of what they were
being taught is unclear.
Hypothetico-deductive reasoning may also provide an
explanation of why there is a significant correlation
between the three sub-categories of mental imagery.

This

concept is an athlete’s ability to use abstract thought to
work through multiple variables in order to predict an
outcome (Cook & Cook, 2005).

In this particular study,

athletes know that they need to heal before they can return
to participation.

An athlete can use hypothetico-deductive

reasoning to plan and understand the importance of
motivating themselves to complete their rehabilitation as
well as correctly performing each exercise that is
assigned.
An unexpected finding was that there was a weak
correlation that was not significant between the length of
rehabilitation and the reported injury severity.

The

assumption could be that a more severe injury would require
a more lengthy rehabilitation program.
do not support this assumption.

However the results

31
Recommendations for Future Research
This study did not find any significant correlations;
between the length of rehab, injury severity or mental
imagery use, however, the information that was found points
toward several recommendations for future research.

The

following section is divided into 1) recommendation for the
current study, 2) recommendations for future studies, and
3) recommendations for the athletic training profession.
The results of this study indicate the need for the
following modifications: a) a clearly defined definition of
the formal mental imagery training for the subjects, b)
compare the athlete’s self report of their injury with
their athletic trainers’ assessments, c) find a more
refined method of measuring severity, d) include athletes
that are not enrolled in rehabilitation, and e) expand
study to involve other collegiate institution and high
schools.
Formal mental imagery training was one of the items on
the demographic sheet.

Participants should have a clear

understanding of the researcher’s definition of formal
mental imagery training in order to answer this item.

The

researcher could also inquire about mental imagery training
the athletes may or may not have received prior to this
study.

32
A second modification to this study would be to
compare the athletes’ self report of their injury with the
assessment of the athletic trainers.

This will give the

researcher an accurate picture of participants’ injuries.
If the athletes injury information is correct then the
severity of their injury would be could be predicted by the
injury itself.

The next adjustment relates to this injury

information reported by the athlete
A refined method of measuring injury severity may give
the athletes more categories to choose from.

This

measurement would assist the researcher in gaining a more
accurate picture of the severity of injury, which may
correlate more closely with the in data received for the
length of rehabilitation.
Another modification to this study would be to
increase the number of participants, since have a small
population (n=40) limits the ability to generalize the
results of the study.

One way to do this would be to

include athlete that are not currently enrolled in
rehabilitation, but have sustained injury.

Including

athletes from other collegiate institutions and high
schools would also broaden the spectrum of the study,
increasing the data pool on when athletes are prone to use
mental imagery.

33
Recommendations for future studies include: a)
implementing a mental imagery training protocol for the
participating athletes and b) implementing a method to
limit socially desirable responding.
A mental imagery training protocol would ensure the
correct use of mental imagery.

This addition would require

a between groups design with one group trained in mental
imagery and a second baseline group without training.
A second recommendation for future studies is to limit
the effect socially desirable responding may have on the
study.

This could be done by emphasizing that the scope of

the study is to measure accuracy rather than a specific
result.

Additionally the athletes should be assured that

their responses will in no way affect their playing status,
will be completely confidential, and will only be used for
the informational purposes in this particular study

Professional Training Implications
The following are recommendations for the athletic
training profession: a) standardize and increase the
training in mental imagery for athletic trainers, b)
determine the athletic trainers’ knowledge, attitudes and
behaviors when handling psychological issues, c) implement

34
a sport psychology certificate program for athletic
training students.
Athletic trainers should increase their awareness of
the psychological aspects of sport injury and increase
their overall knowledge of the functions of mental imagery.
Athletic trainers who are already practicing can enroll in
mental imagery training courses that offer continuing
education units (CEU’s) to build their knowledge base.
CEUs can be attained in the form of course work or
workshops.

Currently Athletic trainers are required to

accumulate 75 CEUs over a 3 year period of time period.
The CEUs are logged and verified with the Athletic Training
Board of Certification.
Practice is the only way to develop the techniques
used to teach mental imagery to athletes.

However,

athletic trainers will not practice a skill they do not
feel is valuable to this profession.

Future studies should

determine the athletic trainer’s knowledge, attitudes and
behaviors when handling the psychological issues, as well
as their knowledge and opinions of the use of mental
imagery techniques.
Another way for athletic trainers to receive training
is to implement a sport psychology certificate program for
both undergraduate students and graduate level athletic

35
training.

A sport psychology program for athletic trainers

would strengthen the relationship between sport
psychologists and athletic trainers.

Clinical Implications
Although this study’s results were not found to be
significant, there is a considerable body of literature
that supports the use of mental imagery to enhance a
rehabilitation program.

It is important for all sports

medicine professional such as sports psychologists, sports
therapists, sport counselors, athletic trainers to have an
understanding of the psychological and developmental issues
faced by the athlete population and how to assist them with
these issues.

These issues could decrease the athlete’s

rate of healing, however athletic trainers can teach goal
setting, self-talk, mental practice, and healing imagery
skills to assist the athlete.

Athletic trainers are often

the first to notice problems, and with the proper knowledge
can inform the athlete about available resources and teach
techniques beneficial to student-athletes for use in their
sport as well as their life outside of athletics.

Athletic

trainers should schedule time when they can formally teach
athletes the various mental imagery skills.

The extended

periods of time that athletes tend to be with athletic

36
trainers are good opportunities for this formal training to
occur.
Goal setting is one psychological skill that appeared
in multiple areas of the literature.

Athletic trainers can

use work with the athletic trainer to set both long and
short term goals that help the athlete stay on track with
their rehabilitation.

Conclusion

There are many possible reasons why the severity of
injury and length of rehabilitation program were not
significantly correlated to the use of the three mental
imagery sub-categories.

One reason is that the reported

severity of injury may have in some way been skewed by the
concept of socially desirable responding.

In the

literature fear of the loss of playing status is a common
fear shared by athletes across the board.

By responding in

a socially desirable manner the participant can underrate
their injury to make it look less severe in order to
continue with their current playing status.
The assumption, when comparing length of
rehabilitation with the severity of an injury, is that
severity would in fact determine the length of

37
rehabilitation.

The correlative was not significant in

this particular study (see table 7).

An explanation could

be that the level 4 severity injuries that were reported to
be the most severe experienced short rehabilitation
programs.

Severe injuries that require surgical repair

tend to not require as lengthy of rehabilitation as nagging
injuries that last an entire season.
Again, the purpose of this study was look for a
correlation between mental imagery and the self reported
length of rehabilitation and severity of injury.

The

results of the hypothesis testing showed that there was not
a significant correlation between mental imagery and
severity of injury or length of rehabilitation.
In the literature there are multiple examples of how
athletes can benefit from the use of mental imagery.

As

athletic trainers we should improve our knowledge of mental
imagery and seek out ways to implement these skills into
our daily treatments and rehabilitation programs.

38
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46

APPENDICES

47

APENDIX A
Review of Literature

48
REVIEW OF LITURATURE

Introduction

College students deal with a range of psychological
issues including stress, anxiety and in some cases
depression.

College student athletes deal with these

issues as well as pressure from coaches, parents, and their
own internal driving force.

Psychological issues have been

related to physical injury; therefore we must identify
effective coping techniques.

Injured athletes work with

athletic trainers on a daily basis to rehabilitate
injuries.

The purpose of this literature review is to

discuss 1) injuries, 2) the athletic trainer 3) college
athletes, 4) intervention methods, 5) mental imagery.

The

purpose of this study is to determine current the level of
mental imagery used by injured collegiate athletes during
rehabilitation.

Injuries

Psychological Antecedents
Psychological antecedents and emotional reactions play
a key role the rehabilitation of an athletic injury.

As

49
reported in the 2006 Consensus Statement, athletic activity
could lead to physical injury and injury could lead to a
variety of psychological issues (Herring, Boyahian-O’Neill,
Coppel, Daniels, Gould, Grana, et al., 2006).
Psychological factors, such as stress, could increase the
athlete’s risk of injury (Herring et al., 2006).

Stress

can lead to attentional changes that can interfere with an
athlete’s performance (Herring et al., 2006).

Psychological Issues of Rehabilitation
Psychological antecedents and emotional reactions play
a key role in athletic injury rehabilitation.

Herring et

al. (2006) reports the use of psychological strategies such
as goal-setting, positive self-talk, cognitive
restructuring and imagery techniques are associated with
faster recovery.

The rehabilitation phase has its own set

of problems including: unreasonable fear of re-injury,
denial of the injury, general impatience and irritability,
rapid mood swings, withdrawal from normal behavior, extreme
guilt about letting the team down, and an obsession with
questions of return to participation (Herring et al.,
2006).

Decisions on return to participation are usually

made by the athletic trainer in conjunction with the team
physician.

50
Athletic Trainer

Athletic trainers are allied health care
professionals, recognized by the American Medical
Association, who collaborate with physicians to optimize
activity and participation of physically active patients
and clients (NATA, 2009).

The typical athletic training

setting includes: professional sports, collegiate athletic,
high school athletics, sports medicine clinics, as well as
health/ fitness clinics (Prentice, 2006).
The six domains of athletic training are: (1) the
prevention of athletic injury and conditions, (2) clinical
evaluation and diagnosis of athletic injury conditions, (3)
the immediate care of athletic injuries and conditions, (4)
treatment rehabilitation and recognition of athletic
conditions, (5) organization and administrative duties, and
(6) professional responsibilities for the profession (NATA,
2009).
Athletic trainers typically spend extended periods of
time with athletes under conditions that promote personal
interactions and trust (Moultan, Molstad, & Turner, 1997).
According to the National Athletic Trainers’ Association
Education Counsel (2009), entry level athletic trainers
should possess certain skills necessary for successful

51
performance in athletic training.

Each of the six domains

of performance has psychological competencies associated
with it.

They include recognizing the psychological signs

and symptoms of athletic injury, practicing effective
communication skills in the areas of health maintenance,
and provide athletes with injury prevention education in
relation to athletic injury.
Athletic training educational competencies and
clinical proficiencies (competencies) are a set of skills
to be mastered by students in entry-level athletic training
programs (NATA, 2009).

The Competencies provide the

certified athletic trainer with the essential knowledge and
skills needed to provide athletic training services to
patients of differing ages and genders and work, and
lifestyle circumstances and needs (NATA, 2009).

The

Commission on Accreditation of Athletic Training Education
(CAATE), requires that the Competencies be used for
curriculum development and education of the student
enrolled in an accredited entry-level education program
(NATA, 2009).
The competencies are categorized into foundational
behaviors of professional practice and are divided into
twelve content areas.

The twelve content areas are (1)

risk management and injury prevention, (2) pathology of

52
injury and illness, (3) orthopedic clinical examinations
and diagnosis, (4) medical conditions and disabilities, (5)
acute care of injuries and illness, (6) therapeutic
modalities, (7) conditioning and rehabilitative exercise,
(8) pharmacology, (9) psychosocial interventions and
referral, (10) nutritional aspects of injuries and
illnesses, (11) health care administration, and (12)
professional development and responsibilities. (NATA, 2009)
Psychosocial interventions and referral will be the
focus of the current study.

Cramer-Roh and Perna (2000)

concluded that psychological factors may either hinder or
facilitate recovery.

Life stress associated with academic

pressure and the decreases in playing time are a few
stressors the college that may affect the athletes rate of
recovery.

Cramer-Roh and Perna (2000) also state that

athletic trainers may benefit from structured education
experiences specific to the NATA psychology/counseling
competencies.
Athletic trainers involved in a 1997 Moultan, Molstad,
and Turner study acknowledged a preference for counseling
athletes whose psychological and emotional problems were
directly associated with sport injury(Moultan et al.,
1997).

53
College Athletes

Collegiate athletes can present to a counselor with
the same developmental issues non-athletes face.
(Fletcher, Benshoff, & Richburg, 2003)

These issues may

include developing independence or establishing one’s sense
of self.

Athletes encounter a variety of psychosocial and

emotional challenges as a function of participation in
sports (Petitpas & Champagne, 1988).

Athletes and non-

athletes face many of the same developmental tasks as they
move from childhood through adolescence to adulthood
(Goldberg, 1991).

An understanding of Erikson’s theory of

psychosocial development will help in understanding the
development of the college student.

Erickson’s theory

includes the following: (1) basic trust vs. mistrust, (2)
autonomy vs. shame and doubt, (3) initiative vs. guilt, (4)
industry vs. inferiority, (5) identity vs. identity
confusion, (6) intimacy vs. isolation, (7) generativity vs.
stagnation, and (8) ego integrity vs. despair (Munley,
1975).
Stage five, identity vs. identity confusion, relates
to adolescence (ages 12-18).

In this stage an individual

must search of an identity that will lead them to
adulthood.

Stage six, intimacy vs. isolation, relates to

54
early adulthood (ages 19-40) (Cramer, Flynn, LaFave, 1997).
In this stage the individual searches for companionship in
another individual.

During the college year these two

stages are most important for their development (Cramer et
al., 1997).
By the time a student reaches college age, he/she
should have reached the stage of formal operational
thought.

Formal operational thought is the final stage of

cognitive development in which an individual learns a skill
known as hypothetico-deductive reasoning (Cook & Cook,
2005).

Hypothetico-deductive reasoning is a skill that

must be mastered for in order for an individual to be able
to plan for future event accurately.

This particular type

of reasoning allows a person to predict the outcome of a
situation that has more than one multiple variables acting
on it (Cook & Cook, 2005).

For example, if an athlete

wants to participate in an athletic event he/she must be
eligible for participation.

Eligibility is determined by

the athlete’s academic standing at the institution, which
can include attendances, grades, and personal conduct.
athlete knows that he/she must attend class, maintain
his/her grades, and exhibit appropriate conduct to be
eligible participants.

An

55
College students and college student athletes have the
same academic responsibilities when it comes to class work,
attendance, and conduct on campus.

Student athletes may

have some leniency when it comes to excused absences due to
athletic competitions, none-the-less, they are still
responsible for completing their class assignments.

In

addition, athletes may need assistance in dealing with a
series of issues including: athletic competition, career
development, psychosocial development, retirement from
sport, and personal clinical issues (Chartrand & Lent,
1987).
The collegiate student athlete must also cope with
additional influences that affect their cognitive, social,
moral, educational and psychosocial development during
their college years (Fletcher et al., 2003).

Fletcher et

al. (2003) stated an athlete’s emotional well-being is
closely linked to their success on the field.

Athletes

often deal with fear and disappointment that may come with
their team loosing an important game or fear of performance
anxiety.

The fear associated with performance is the fear

of losing the playing time because of injury, fear of being
cut from the team, and the fear of being forced to retire
(Fletcher et al., 2003).

Retirement can be due to injury,

56
graduation from high school or college, or retirement from
professional sports.

Intervention Methods

Student-athletes are the most recognized populations
on college campuses (Fletcher et al., 2003).

They attract

honors and praise for their successes along with resentment
of their privileges and special treatment (Fletcher et al.,
2003).

College students and college student-athletes are

at the same fundamental age therefore they face the same
developmental issues.

The difference is that the consuming

nature of athletics hinders the college student athletes’
mastery of the developmentally appropriate skills such as
developing his/her sense of self (Fletcher et al., 2003).
Johnson (2000), on the other hand, makes the distinction
that the athletic population would more readily adhere to a
mental imagery protocol because the practice necessary to
master these psychological skills resemble the practice of
their sport.

57
Mental Imagery

Mental imagery is defined as creating an image within
the mind without external stimuli.

Mental imagery has been

used in training and competition; however, little research
has been published describing mental imagery in the context
of rehabilitation.

Mental Imagery techniques can be used

as preventive treatment for stress associated with trouble
between teammates, coaches, fans, loss of playing status,
or the event itself (Green, 1992).

Throughout the search

for literature on mental imagery, three categories of
imagery have surfaced: cognitive imagery, healing imagery,
and motivational imagery.

The purpose of this review is to

provide information about the three categories of imagery
and how each can benefit the athlete during injury
rehabilitation.

Cognitive Imagery
Cognitive Imagery is the use of mental imagery to
enhance specific sports skills and to plan strategies
before during and after competition (Cox, 2001).

Cognitive

imagery can be use before and during the performance of a
sports skill.

Imagery can be used as practice between

competitions or immediately before a performance to ensure

58
proper skill execution (Malouff, McGee, Halford, & Rooke,
2008).

In 2008, Malouff et al. used a group of 115

participants who were enrolled in a tennis serving
competition which tested the effectiveness of three mental
rehearsal techniques.

The three condition groups were

self-instruction, imagery, and serve as usual.

A random

number table was used to assign each of the participants to
one of the three condition groups.

The first group was

instructed to use one of the cues from the this list: see
the target zone, line up toes, toss the ball to contact
height, straight toss, bend, see the ball, see where to
contact the ball, reach up contact the ball where you want
(Malouff et al, 2008).

The second group had the

participant imagining the entire serve from beginning to
end.

The participant should visualize how he/she would

move, what he/she sees, and how it feels to go through each
movement (Malouff et al., 2008).

The third group was

considered the control or no intervention group.

These

participants were instructed to serve as they would
normally.
According to the results of the Malouff et al. (2008)
study, the tennis players that used positive imagery
(p=.01) and self instruction (p=.032) performed better
during competition than the tennis player that served

59
without the intervention.

Malouff et al. (2008) also

reported no significant difference between the positive
imagery and the self-instruction group.
A 1980 study on mental imagery by Weinberg, Gould,
Jackson, and Barnes reported different results.

Malouff et

al. (2008) credited these differences to the
dissimilarities between the two studies.

The differences

noted were: the imagery in the present study had a positive
outcome, the self-instructions condition involved one
instruction at a time rather than a set of instructions,
each participant received each condition, there was no
competition, the serving outcome measured both speed and
accuracy, and previous study included beginners while the
present study included participants that have participated
in a competitive league (Malouff et al., 2008).
Fear of physical injury seems to be a common source of
worry, even a possible reason for leaving the sport (Chase,
Magyar, & Drake, 2005).

In a 2005 study, Chase et al.

interviewed gymnasts ages 12-17.

All participants in the

study were from the Midwest and competed at level 7-10.
These subjects had a training age of approx 8.7 years.

In

this study the gymnasts were asked questions about the
types of injuries occurring in gymnastics, reasons they
participate, their fear of injury, sources of self-efficacy

60
(i.e., self-confidence); and mental/physical strategies
used to overcome fear of injury.
A person’s self-efficacy will help them overcome the
fear of injury and associated anxiety.

There are four

factors known to affect ones self-efficacy: performance
accomplishments, vicarious experience, verbal persuasion,
and physiological arousal/emotion.

In order to conquer the

fear of injury, athletes must learn skills to manage the
fear.

Mental imagery/rehearsal is one technique adopted by

athletes to manage fear as well as improving performance
and self-confidence (Chase et al., 2005).

These techniques

are often implemented by athletic trainers and as well as
sport psychologist.

Healing Imagery
The scope of practice of certified athletic trainers
includes aspects of sport psychology techniques practiced
by sport psychologists.

Mental imagery can be implemented

with injured athletes during rehabilitation to promote
healing, to control stress, and to promote and maintain a
positive mindset (Hamson-Utley & Vazquez, 2008).

There are

studies that credit shorter recovery times from injury,
surgical procedures, and disease to the use of healing
imagery during.

Egbert, Battit, Welch and Bartlett (1964)

61
(as cited in Kiecolt-Glaser, Page, Marucha, MacCallum, and
Glaser, 1998) reported that anesthesiologists paid brief
visits to patients and provided them post surgical
information and taught them relaxation techniques to reduce
pain.

The patients that received these extra visits

required less pain medication and left the hospital and
average of 2.7 day sooner that the patients receiving
routine care (Egbert et al., 1964).
Scherzer, Brewer, Cornelius, Van Raalte, Petitpas, and
Sklar et al. (2001) completed a study measuring the
correlation between psychological skills used and adherence
to the rehabilitation program.

Fifty-four participants

were going through rehabilitation for an anterior crutiate
ligament (ACL) repair.

The ACL is the ligament that the

knee that limits forward movement between femur (thigh
bone) and the tibia (shin bone).

The Sports Injury Survey

used in the study measured goal setting, healing-imagery,
and positive self-talk.

This study suggested that the

effect of imagery on rehabilitation occur separately from
how closely the athlete follows rehabilitation program
(Scherzer et al., 2001).
Driediger, Hall, and Callow (2006) proposed that
imagery can be used to decrease the amount of stress
associated with injury.

Athletes undergoing rehabilitation

62
in this study consistently described using imagery before
or during their rehabilitation sessions to help control
their technique.

When used this way, imagery use could

help decrease the chance of reinjury (Driediger et al.,
2006).
Ievleva and Orlick (1991) examined whether athletes
with fast-healing knee and ankle injuries demonstrated
greater use of psychological strategies and skills than
those with slow-healing injuries.

The results of the study

revealed that fast-healing athletes used more goal setting,
positive talk strategies, and more healing imagery than did
slow-healing athletes (Ievleva & Orlick 1991).

These

results suggest mental imagery can have a positive effect
on the rate of healing.

Pain Management
Pain is one of the most frequently observed conditions
by sports medicine providers when treating athletes
(Brewer, Jeffers, Petitpas, & Van Raalte, 1994).

Law et

al. (2006) used the Athletic Injury Imagery Questionaire-2
in conjunction with the VAS and the LEFS.

The VAS for pain

is a ranking system that allows the client to give a visual
representation of their pain level.

A typical item in a

VAS is a line with marked with the values zero through ten.

63
The client places a mark on the line that visually
represents his/her current pain level.

The LEFS is a

series of tests used the check client’s ability to perform
certain movements with the leg.
These questionnaires were used to determine if
athletes who used imagery for pain management employed more
cognitive, motivational, and healing imagery than the
athletes did not (Law et al., 2006).

The Law et al. (2006)

study further states that athletes who employed imagery to
alleviate pain were more satisfied with their
rehabilitation than athletes who did not use imagery.
Athletes often experience pain during different phases
of the rehabilitation program.

The purpose of the early

phase of rehab is it to control pain and the other initial
signs of inflammation (Prentice, 2005).

Law et al. (2006)

reports mental imagery should be used by injured athletes
to manage pain; however these results do not translate to
improved functionality or changes in the athletes’ degree
of pain.

Law et al. (2006) proposed that imagery use

during rehabilitation does increase the athletes’
satisfaction with the rehabilitation program.

64
Motivational Imagery
Mental imagery and mental rehearsal has many uses in
athletics.

Motivational Imagery is the use of mental

imagery to experience goal attainment, effective coping,
and/or arousal management.
Syrjala, Donaldson, Davis, Kippes and Carr (1995)
studied 94 patients that have been diagnosed with cancer.
Each of the participants recently had or were preparing for
their first bone marrow transplantation (BMT).

A bone

marrow transplant is a surgical procedure that replaces
lost or damaged bone marrow tissue.

The interventions

associated with this study are treatment as usual (TAU),
therapist support (TS), relaxation and imagery(R&I), and
cognitive behavior skills training (CB).

The R&I group

received pre-hospital training sessions that included oneon-one interactions, written instructions, audio relaxation
tapes and home practice.

Patients were provided with

information about the pain and nausea associated with the
treatments.

Each patient was seen twice a week for 20-40

minutes (Syrjala et al., 1995).

In the first session

patients were instructed to use deep breathing and
progressive relaxation techniques.

The second session

involved autogenic relaxation, a technique which involves

65
passive concentration and body awareness of a specific
sensation (Syrjala et al., 1995).
Syrjala et al. (1995) reported both the cognitive
behavior training (p=.0071) and the relaxation and imagery
(p=.0088) groups experienced a reduction in pain after
their BMT.

The difference between the CB and R&I group was

not significant.

Neither CB nor R&I groups reported a

significant change in nausea during their treatment.

The

information for pain and nausea was confirmed in an
analysis of the patients' perceptions of the helpfulness of
the treatments for coping with the symptoms.

Stress and anxiety
Hinderliter and Cardinal (2007) purposed six concepts
are: social support, confidence and competence, refer,
accommodate, psychological skills, and educate.

The

concepts identified can be used by athletic trainers when
working with athletes.

With the increased interactions of

between the athlete and the athletic trainers they should
be able to determine which of these concepts the athlete
needs the most work.
Social Support implies the use of a group of people
the athlete trusts and are capable helping when needed.
The athlete’s support group can include teammates, coaches,

66
parents, and people who have experienced the same type of
injury.

Social support is most often used during

situations involving substance abuse, bereavement, terminal
illness, parenting, and spirituality (Hinderliter &
Cardinal, 2007).

According to Bloom, Horton, McCrory, and

Johnston (2004), support groups may be as beneficial for
physical injuries as they have been for substance abuse
rehabilitation (Bloom et al., 2004).
The clinician could enhance the process of improving
the patients’ confidence and competence which can
positively influence the recovery process (Hinderliter &
Cardinal, 2007).

The clinician skilled in modeling

confidence and competence can facilitate the patient’s
development of the same characteristics.

Early success in

the rehabilitation process can be used to boost the athlete
confidence, which could further motivate them to complete
their rehabilitation.
In some case the clinician is unable to handle the
psychological distress associated with injury.

In such

cases, it is important for the clinician to recognize when
to refer the individual to an outside source (Hinderliter &
Cardinal, 2007).
Each athlete that enters the athletic training room
has a unique.

If at all possible a clinician’s should

67
accommodate these needs, to promote the relationship
between the clinician and the athlete.

For an example a

person may prefer heat application instead of cold
application (Hinderliter & Cardinal, 2007).

The clinician

needs to have the ability to explain why what the athlete
wants may not what is best for them at that particular
moment (Hinderliter & Cardinal, 2007).

For example, the

athletic trainer needs to inform the athlete when cold
therapy is indicated instead of heat therapy.
Psychological skills such as imagery, relaxation, and
goal-setting can have a positive influence on the recovery
of an injury.

The clinician needs to have adequate skills

to effectively implement this technique (Hinderliter &
Cardinal, 2007).

One proposed method is the use of a

rehabilitation journal to keep track of the recovery
process.
The final of Hinderliter and Cardinal’s six concepts
is the need to educate to the athlete about the situation.
When the athlete has a clear understanding of the injury,
they will know what to expect in each phase of healing.
The athletic trainer should speak clearly and avoid
technical jargon (Hinderliter & Cardinal, 2007).

68
Positive Mind Set
Following injury, an athlete may have negative
thoughts including the fear of loss of playing status.
Green (1992) proposed a method of creating mental images of
oneself for each phase of healing.

For example; an athlete

has just injured his ankle.

His “possible self #1” should

decrease pain and swelling.

His “possible self #2” is

responsible for getting back on the field.

The third

possible self is responsible for getting back to full speed
and so on (Green, 1992).

This technique provides that

athlete with a mental representation of each goal he/she
wants to accomplish.

Mental Imagery and Rehabilitation
A decrease in the ability of to maximally activate a
muscle is a well-known complication of therapeutic
immobilization (Newsom, Knight, & Balnave, 2003).
Immobilization is often necessary following a severe
athletic injury.

“An observation that training involving

imagined muscle contractions can result in increases in
strength comparable to those elicited by physical training
has been interpreted as indicating that mental imagery can
influence the design, and planning of rehabilitation
protocol” (Yue & Cole, 1992).

Newsom et al. (2003)

69
proposed mental imagery may limit strength loss in
immobilized muscles by stimulating the central pathways
responsible for motor control and prevent neuro-motor
adaptations.
The Newsom et al. (2003) study used 17 participants,
13 female and 4 males.

Each participant had their non-

dominant arm casted from metacarpals (the bones in the
palm) to just below the elbow.

The clinician asked

participants to imagine squeezing a rubber ball as tightly
as possible (Newsom et al., 2003).

The participants were

reminded to avoid actual muscle contraction.

The treatment

sessions were 3 times a day for 5 minutes each.

The

results of this study state there was a 16.3% loss in grip
strength in the control, and a 1.5% loss on grip strength
for the experimental group.

These results suggest mental

imagery may be beneficial in reducing the loss of strength
associated with immobilization (Newsom et al., 2003).
Central factors within the brain have been implicated
in the strength gains occurring in response to mental
imagery (Newsom et al., 2003).

Imagined activities result

in cortical activity that is specific to the areas
associated with the muscle being mentally exercised
(Dachateau, 2002).

Yue and Cole also compared three types

of strength training: physical strength training, mental

70
strength training, and imagined strength training.

They

found that the initial phase of both training regimens were
identical.

They hypothesized that the changes in central

programming were responsible for the strength gain observed
in the imagery (Yue & Cole, 1992).

Summary

Mental imagery is defined as creating an image within
the mind without external stimuli.

Mental Imagery has been

used in training and competition however little research
has been published describing mental imagery in the context
of rehabilitation.

The purpose of this review was to

provide information about the three categories of imagery
and how each can benefit the athlete during athletic injury
rehabilitation.

Motivational, cognitive, and healing

imagery were the three headings discussed in this
literature review.

Each type of imagery plays a specific

role in the rehabilitation of athletic injury.
Cognitive imagery can be used to help an athlete
regain skills that have diminished during the period of
time that the athlete was injured.

Cognitive imagery is

the use of mental imagery to experience specific sports
skills and to plan strategies before during and after

71
competition.

When an athlete is injured they are sometimes

unable to perform in their sport.

Cognitive imagery could

be a method used to allow them to experience their sport
without the risk of reinjury.
Motivational imagery can be implemented with injured
athletes during rehabilitation to promote healing, to
control stress, and to promote and maintain a positive mind
set (Hamson-Utley & Vazquez, 2008)

Athletes have to deal

with pressure from coaches, parents, and their personal
desire to return to participation.

One of the attributes

of healing imagery is its ability to help an athlete
maintain a positive mood and stay focused on the outcomes
of the rehabilitation program.
Motivational imagery can be used to help the athlete
get through difficult parts of their rehabilitation.
Motivational imagery is the use of mental imagery to
experience goal attainment, effective coping, and/or
arousal management.

If an athlete reaches a plateau in

their rehabilitation, motivational imagery can be used to
refocus their efforts on completing the task and helping
reach the next step toward returning to participation.
At stated above, mental imagery has multiple uses in
athletic injury rehabilitation.

College students deal with

a variety of psychological issues including stress, anxiety

72
and in some cases depression.

College student athletes

deal with the pressure of performing at high level on the
playing field as well as maintaining the appropriate
academic standing to be eligible for participation.
Psychological issues have been related to physical
injury; therefore we should teach effective coping
techniques to our athletes to reduce the risk of injury.
Injured athletes work with athletic trainers on a daily
basis to rehabilitate injures.

The purpose of this

literature review was to discuss 1) injuries, 2) the
athletic trainer, 3) college athletes, 4) intervention
methods, 5) types of mental imagery.

The purpose of this

study is to determine current level of mental imagery use
among injures collegiate athletes.
often the first

Athletic trainers are

to notice problems; and with the proper

knowledge can inform the athlete about the resources
available, as well as teach techniques to the student can
use in their life outside of sports.

Furthermore, CAATE

standards discuss the need for athletic trainers to be
competent and proficient when dealing with psychological
issues concerning athletes and the physically active
population.

73

APENDIX B
The Problem

74

Problem Statement
The psychological response to injury can lead to
further injury or a lengthen rehabilitation. The mental
imagery techniques discussed in this study can be
implemented to help athletes deal with the stressor
associated with injury and injury rehabilitation.

The

techniques developed can stay with the athlete as he/she
transitions to the next phase of his/her life.

Definition of Terms
The following terms have been defined to help with the
overall understanding of this particular study:
1. Mental Imagery – The total score of all items on the
Athletic Injury Imagery Questionnaire-2.
2. Cognitive Imagery – The sub-score of items 2, 6, 7 and
10 on the Athletic Injury Imagery Questionnaire-2.
3. Healing Imagery – The sub-score of items 1, 4, 8 and
11 on the Athletic Injury Imagery Questionnaire-2.
4. Motivational Imagery – The sub-score of items 3, 5, 9,
and 12 on the Athletic Injury Imagery Questionnaire-2.
5. Formal Mental Imagery training is defined as any
interaction between a sport medicine professional
(i.e. athletic trainers, sport psychologist, sport

75
therapist, physical therapist, or sports counselor)
with the purpose of teaching skills that the athlete
can use to cope with psychological issues associated
with injury and injury rehabilitation.

Basic Assumptions
The following are the basic assumptions that can be
made for this study:
1. All participants are currently undergoing
rehabilitation for a current injury.
2. All participants will answer the each item on the
Athletic Injury Imagery Questionaire-2 to the best of
their ability.
3. Injuries reported will represent all levels of injury
described on the American Sports Data Sports Injury
Report.
4. Athletes have not received any formal training in
mental imagery prior to this study.

Limitations of the Study
The following are the possible limitation of this study:
1. Only student-athletes that are currently going through
rehabilitation were questioned.

76
2. Only student-athlete at California University of
Pennsylvania were issued a questionnaire
3. All participants were volunteers

Significance of the Study
This study will increase the research of the mental
imagery and it’s the benefits receive from using
psychological stress reduce techniques.
It is important for all sports medicine professional
such as sports psychologists, sports therapists, sport
counselors, athletic trainers to have an understanding of
the psychological issues and how to assist athletes with
these issues.

Athletic trainers are often the first notice

problems and with the proper knowledge can inform the
athlete on the resources available and teach techniques for
student-athletes to use in their lives outside of sports.

77

Appendix C
Additional Methods

78

Appendix C1
Informed Consent

79

80

Appendix C2
Student Athlete Response Form

81

Demographic Sheet

Sport________________________________
Year(s) of Participation_____________
Position_____________________________
Injury_______________________________
Length of Rehab______________________
Select
One

Severity of Injury
Level 1
Level 2
Level 3
Level 4

Injury did not interfere with
subsequent participation
Injury prevented participation
on at least one or more future
occasions, but for less than a
month
Injury prevented participation
for at least a month
Injury prevented participation
for at least a month and
resulted in emergency room
treatment, overnight hospital
stay, surgery and/or ongoing
physical therapy

Have you had formal training in the
techniques of mental imagery?

_________________

82

83

Appendix C3
Institutional Review Board:
California University of Pennsylvania

84

85

86

87

88

89

90

APENDIX C4
Athletic Director Consent Form

91

92
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ABSTRACT
Title:

THE LEVEL OF MENTAL IMAGERY USE BY INJURED
COLLEGIATE DURING REHABILITATION

Researcher:

Brandon F. McClendon

Adviser:

Dr. Tom Kinsey

Date:

May 2009

Research Type:

Master’s Thesis

Content:

Mental imagery has been shown as an
effective tool in reducing the psychological
issues associated with athletic injury.
Mental imagery has multiple functions that
can be used in athletics and in life after
athletics.

Objective:

The purpose of this study is to examine the
level of mental imagery use by injured
athletes during rehabilitation as it relates
to length of rehabilitation and the severity
if the injury.

Setting:

The participants who complete this survey
did so in a controlled laboratory setting in
person.

Design:

The correlation between mental imagery and
severity of injury/length of rehabilitation
was test using the Pearson product
correlation. Mental imagery was divided
into three sub-categories, motivation,
cognitive, and healing imagery.

Participants:

Forty injured collegiate athletes currently
rehabilitation and injury working with an
Athletic Trainer at California University of
Pennsylvania

Interventions:

The correlation between mental imagery and
severity of injury/length of rehabilitation
was test using the Pearson product
correlation. Mental imagery was divided
into three sub-categories, motivation,
cognitive, and healing imagery.

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Main Outcome
Measures:

Questionnaire packet was divided into a
demographic sheet demographic sheet was
contained the two variables length of
rehabilitation and severity of injury. The
sub-scores received from the AIIQ-2 were the
motivational sub score, the cognitive
imagery sub-score and the healing imagery
sub score. The researcher performed a
Pearson Product moment correlation between
the variables.

Results:

The primary findings of this particular
study was that there was not a significant
correlation between the reported length of
rehabilitation and severity of injury and
the cognitive imagery sub-score,
motivational imagery sub score, and the
healing imagery sub score.

Conclusion:

This study did not find a significant
correlation between the severity of
injury/length of rehabilitation and the use
of the three mental imagery sub-categories.
This results exposed several necessary
modification to the current study. The
results of this study showed a need for in
training in mental imagery for athletes, and
athletic trainers. As athletic trainers we
should improve our awareness of
psychological aspect of injuries. Athletic
trainers are often the first to notice
problems, and with the proper knowledge can
inform the athlete about available resources
and teach techniques beneficial to studentathletes for use in their sport as well as
their life outside of athletics.