Functional Outcomes and Psychological Benefits of Active Video Games in the Rehabilitation of Lateral Ankle Sprains: A Case Report

in Journal of Sport Rehabilitation

Context: The use of active video games (AVG) as a treatment modality in the rehabilitation context is increasing. However, little is known about the functional outcomes and psychological benefits of such rehabilitation in college athletes with lateral ankle sprains (LASs). Objective: To examine functional outcomes and psychological benefits of AVG-aided rehabilitation program for LAS. Design: A mixed-methods, single-subject case series design. Setting: College athletic training clinic. Patients: Two female college soccer players who sustained LAS (grades I and II) during sport participation. Intervention: A 4-week balance training program. One patient completed balance exercises using AVG, whereas the other patient completed traditional balance exercises. Main Outcome Measures: Several validated instruments were used to evaluate different functional outcomes and psychological factors: balance (Balance Error Scoring System, Star Excursion Balance Test), rehabilitation adherence (Rehabilitation Adherence Measure for Athletic Training), foot and ankle function (Foot and Ankle Ability Measure), perceptions of pain (Visual Analog Scale for pain), perceived readiness to return to sport (Injury-Psychological Readiness to Return to Sport Scale), and mood (Brunel Mood Scale). Results: It appears that the balance training protocols (AVG and traditional balance exercises) were equally effective in restoring patient’s balance to functional levels. Despite very individualistic processes of rehabilitation, the participants’ perceived pain, perceived readiness to return to sport, and mood states were closely linked with objective and subjective functional measures of progress. Conclusions: Based on the results, AVG has the potential to provide more versatility into the static and dynamic postural control exercises typically used following acute LAS. Moreover, the current results support the existing psychological and biopsychosocial theoretical conceptualizations of athletes’ responses to injuries and rehabilitation process.

Lateral ankle sprains (LASs) are among the most common injuries encountered during sport and exercise participation.13 Typically, a consequence of either extrinsic (eg, direct blow to the ankle or landing on an opponent’s foot) or intrinsic (eg, proprioception deficits, mechanical laxity, or a previous history of ankle sprains) reasons,4 the exact cause of LAS is likely multifactorial. Regardless of the cause, once occurred, individuals with LAS are known to have proprioceptive deficits as a result of damage to the sensory mechanoreceptors in the ankle.5

As is the case with other musculoskeletal sport injury rehabilitation programs, the aim of LAS rehabilitation is to ensure athletes’ physical and psychological readiness6,7 to return to sport at preinjury (or higher) level of performance as quickly and safely as possible, while also minimizing any factors that could lead to reinjury. As such, it is imperative to ensure appropriate care that includes both physical and psychological components,8 as without it, there is no “guarantee that the athlete will return to full overall functioning and highest level of sports performance”9(pxv). From the physical perspective, acute care for LAS typically includes the protocol of protection, rest, ice, compression, and elevation (PRICE) to control pain and swelling and to restore normal function as soon as possible.10,11 Strength training is then incorporated into the rehabilitation protocol to address weaknesses that occurred as a result of the injury,1214 and proprioceptive and postural control deficits are typically addressed via balance exercises, an essential component of the LAS rehabilitation.15,16 Psychologically, some of the key factors that are imperative to address during injury rehabilitation include adherence to/compliance (ie, a behavior) with treatment,1719 maintaining positive mood17,18,20 (ie, an affect), and having confidence in returning back to activity20,21 (ie, a cognition).

Conceptually, the aforementioned connections between physical and psychological factors are explained through the biopsychosocial model of sport injury rehabilitation.22 The model proposes a bidirectional interaction between biological (eg, tissue repair, nutrition, sleep), psychological (ie, personality, cognition, affect, behavior), and social/contextual (eg, social network, rehabilitation environment) factors, all of which are also influenced by characteristics of injury (eg, type, cause, severity) and a range of sociodemographic (eg, age, gender) factors. The aforementioned biopsychosocial factors are also said to influence both the intermediate (eg, range of motion, pain, rate of recovery) and overall (eg, functional performance, readiness to return to sport) rehabilitation outcomes,22 with psychological factors also proposed as having a bidirectional relationship with both intermediate and overall biopsychosocial outcomes.22

Support for the aforementioned conceptualization has also been documented in the literature. Relevant to the current study, it is known that the rehabilitation environment that fosters positive psychological responses (ie, behaviors, affect, and cognitions) to injury20 and contains systematic and appropriate rehabilitation goals23 has been associated with both higher20 and faster23 rate of returning to sport following athletic injury. From an injured athletes’ perspective, research findings suggest that sport medicine professionals (ie, athletic trainers, physiotherapists) who work with injured athletes during rehabilitation (a social/contextual factor) are expected to address physical aspects of the injury, while also addressing any relevant psychological aspects of the injury in a subtle and indirect manner.24 The sport medicine professionals themselves have also indicated that to facilitate successful coping with injury and the subsequent rehabilitation/recovery process, they are typically employing 3 main biopsychosocial strategies: (1) creating variability in rehabilitation exercises, (2) setting short-term goals, and (3) encouraging positive self-talk.17,18,25,26

One novel way to create variability in functional rehabilitation protocols, while also providing the desired subtle and indirect psychological support, is through the introduction of active video games (AVG) as an adjunct to, or replacement for, traditional treatment modality during rehabilitation. Albeit conducted predominantly with elderly populations receiving balance training and undergoing stroke recovery,2729 research is demonstrating comparable functional rehabilitation outcomes to traditional treatment modalities.27,28,30,31 From a psychological perspective, existing research has demonstrated equivocal support for a range of behavioral (eg, adherence/compliance, engagement, and social relationships), emotional (eg, mood, feelings of excitement, and flow), and cognitive benefits (eg, enjoyment, motivation, positive effects on self-efficacy, and confidence).32

Although the aforementioned results may not be directly comparable with competitive athlete populations, use of AVG has also been proposed to be beneficial for sport injury rehabilitation because they offer both clients and practitioners new ways of thinking about athletic injury.33 To date, only 2 empirical investigations with previously injured athletes exist.34 In their study, Manley et al34 conducted trials of AVG activities with previously injured elite athletes. The athletes were then interviewed about their perceptions and experiences of the usefulness of AVG in relation to their past sport injury rehabilitation. The results indicated that despite some skepticism about the efficacy of AVG for functional rehabilitation, AVG were perceived overall as a potential adjunct to rehabilitation protocols to help facilitate positive emotional responses and increase adherence.34 The second published study to date aimed to explore the outcomes of an Xbox Kinect intervention on balance ability, enjoyment, and compliance for previously injured young competitive male athletes.35 Using a randomized pre–post-test design, the participants were split into 3 groups: the Xbox Kinect group, the traditional (TRAD) balance exercise group, and the control group (no intervention). The results revealed somewhat comparable balance stability improvements for the Xbox Kinect and TRAD balance exercise groups, with the Xbox Kinect group reporting higher balance improvements. Those in the Xbox Kinect group reported higher enjoyment during the intervention; however, no significant differences in self-reported treatment compliance between the experimental groups were found.35 Although the study did use a randomized trial design, it did not include measures of patient outcome (pain or function) or use reliable and valid measures of rehabilitation adherence or perceived readiness to return to sport. Furthermore, no known studies have investigated the functional outcomes and psychological benefits of AVG concurrently with currently injured athletes. Thus, the purpose of this study is to describe the functional outcomes and psychological benefits of using AVG in the rehabilitation of acute LAS.

Methods

Design

To gain an initial understanding of how AVG could be routinely incorporated into LAS rehabilitation, we employed a case report design. This design provided the opportunity to accurately measure different aspects of 2 patients’ functional and psychological factors across time and is routinely used in research investigating psychophysiological responses to a behavior or specific activity.36 The research protocols (intake, clinician-rated measures, and rehabilitation protocol) were all completed by the same athletic trainer, who also collected the patient-rated measures.

Intake Procedure

In the event of an acute ankle sprain of a student-athlete at a Midwestern NCAA Division I university, primary care and immediate injury management were provided by a certified athletic trainer. The researcher (ie, a certified athletic trainer) who conducted the intervention for both participants was then contacted and met with the potential participant, explained the nature and purpose of the study, and addressed any arising questions prior to obtaining consent.

Participants

Two student-athletes from the university’s women’s soccer team met the inclusion criteria for this study: (1) they had sustained an acute LAS that required absence from practice or competitive participation for >24 hours, (2) the injury was diagnosed by either a licensed athletic trainer or a physician, (3) they were otherwise healthy with no active injuries to the knee or hip, and (4) they were able to complete the baseline testing no more than 36 hours after the injury incident. To best match the 2 participants, we wanted to rule out any evidence of (1) radiologically confirmed fracture of the lower leg, ankle, or foot; (2) injury to the distal tibiofibular ligament or syndesmosis; (3) the need for surgical intervention; (4) pregnancy at the time of injury; and/or (5) a condition affecting the vestibular system.

Participant A (AVG Participant)

Participant A was a 21-year-old female NCAA Division I soccer player (height = 160 cm, weight = 52.3 kg), who routinely saw extensive minutes of play. She previously competed in gymnastics and had a history of 2 previous sprains, the most recent being over 12 months prior. Her current injury occurred during a game, while she was attempting to make a slide tackle on an opponent when she reported that she “jammed” her foot into the ground and inverted her ankle. Ligamentous testing revealed minor laxity with a firm end feel, moderate swelling, and pain 5/10. Based on these clinical findings, the athletic trainer diagnosed a grade II LAS and immediately began to care for the injury using the PRICE approach. Further diagnostic testing was not performed. Following the injury, the participant reported moderate levels of pain and swelling, and progressed well through the acute care and strength-training phases of the rehabilitation. Her balance training phase began during week 2 following the injury. After 3 balance training sessions, she met the commonly used clinical guidelines for return to play and, thus, was cleared to return to play with her ankle taped to further protect from reinjury. She played in a soccer game the following day without incident; however, she woke up the next morning with a drastic increase in ankle pain. The athletic trainer referred the participant to the team physician for further diagnostic testing. Radiographic (X-ray and magnetic resonance imaging) testing showed no additional bony or muscular damage, and the treatment was continued for LAS as initially diagnosed. After a few days focusing treatment on pain control, she was able to resume the rehabilitation protocol. She completed 14 balance sessions over a 4-week protocol.

Participant B (TRAD Balance Exercises Participant)

Participant B was a 19-year-old female NCAA Division I soccer player (height = 170.2 cm, weight = 58.2 kg), who rarely saw playing time in competitions during the season. She had a history of 1 previous LAS that was many years ago. During a practice session, she reported that when she attempted to block a teammate’s shot with her foot, the ball struck on the inside of her ankle causing it to invert. Ligamentous testing revealed no laxity, and minimal swelling was present, and she reported mild pain (>3/10). Based on these clinical findings, the athletic trainer diagnosed her with a grade I LAS, and immediately began to care for the injury using the PRICE approach. Further diagnostic testing was not performed. Following the injury, the participant reported minimal swelling and mild pain. After 3 days of acute care and strengthening, she was ready to start balance training. Over the 4-week protocol, the participant was able to complete only 12 balance sessions due to class conflicts and illnesses.

Clinician-Rated Measures

After the participants consented to be part of the research study, demographic information was collected (age, height, weight, injury severity classification, sports history, and previous LAS history). All baseline measures (see Figure 1) were completed within 36 hours of the injury onset. All measurements are described in the following sections and then further explained in the rehabilitation procedures at the appropriate phase.

Figure 1
Figure 1

—Flowchart of the study intervention. AROM indicates active range of motion; BESS, Balance Error Scoring System; BRUMS, Brunel Mood Scale; FAAM, Foot and Ankle Ability Measure; FAAM-S, Foot and Ankle Ability Measure-Sports; I-PRRS, Injury-Psychological Readiness to Return to Sport; RAdMAT, Rehabilitation Adherence Measure for Athletic Training; RTP, Return to play; SEBT, Star Excursion Balance Test.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Balance

We used 2 balance measures to assess static (Balance Error Scoring System, BESS) and dynamic (Star Excursion Balance Test, SEBT) balance. The BESS is an objective measure of assessing static postural stability. The modified BESS was used to assess static balance by standing as still as possible for 20 seconds in different stances: (1) a single-leg stance (SLS) on firm ground, (2) a tandem (injured foot directly behind uninjured foot) stance on firm ground, (3) an SLS on an AIREX® (Sins, Switzerland) foam pad, and (4) a tandem stance on an AIREX® foam pad. Each participant completed a practice trial in each stance followed by 2 recorded trials. The 2 recorded trials were averaged together. The BESS has shown good intertester reliability (ICC values between .78 and .96).37

The SEBT is a test that measures dynamic balance. As per previous recommendations,38 the SEBT was used to measure reach distances to 3 directions: anterior, posteromedial, and posterolateral while having the injured limb as the stance leg. Each participant completed 6 practice trials in each direction followed by 3 recorded trials. The 3 recorded trials were averaged together. All reach distances were normalized by limb length measuring from the anterior superior iliac spine to the medial malleolus and reported as a percentage of limb length. The SEBT has been proven reliable with intratester reliability estimates of .67 to .96 and intertester reliability estimates of .35 to .93.38

Rehabilitation Adherence

The Rehabilitation Adherence Measure for Athletic Training (RAdMAT)39 is a 16-item clinician-rated questionnaire measuring 3 subscales, namely attendance/participation, communication, and attitude/effort, on a 4-point Likert scale (1 = never, 4 = always). The measure has been shown to correlate well with previously established measures of adherence and is able to differentiate between athletes exhibiting low, moderate, and high amounts of rehabilitation adherence.39

Patient-Reported Measures

Foot and Ankle Function

The Foot and Ankle Ability Measure (FAAM) is designed to detect changes in ankle function over time. It is a self-report questionnaire consisting of 2 subscales, namely the activities of daily living (FAAM, 21 items)40 and sports (FAAM-S, 8 items),40 and measures patients ability to complete different tasks on a 4-point scale: 0 (unable to do) to 4 (no difficulty). The measure has been shown to be reliable when compared with other functional ability questionnaires.41

Pain

The Visual Analog Scale (VAS) is a 10-cm-long unidimensional scale that asks the participant to rate their level of pain from 0 (no pain) to 10 (most terrible pain possible). This scale has been widely used42 and has been shown to have a good test–retest reliability (ICC = .87).43

Mood

The Brunel Mood Scale (BRUMS)44 is a 24-item self-report questionnaire measuring 6 different mood descriptors (anger, confusion, depression, fatigue, tension, and vigor) on a 5-point Likert scale (0 = not at all, 4 = extremely). Preliminary evidence has shown adequate fit through confirmatory factor analysis and also has satisfactory construct validity when compared with previously established mood state measures.44

Psychological Readiness to Return to Sport

The Injury-Psychological Readiness to Return to Sport (I-PRRS) scale21 is a 6-item self-report questionnaire measuring injured athletes’ perceptions of their readiness to return to sport on a 10-point scale. Preliminary evidence has shown reliability coefficients >.70.21

Rehabilitation Procedure

As shown in Figure 1, the lateral ankle rehabilitation consisted of routine standard of care procedures through the acute care and strength-training phases. In the acute care phase, a standard treatment protocol of PRICE occurred. In the absence of established optimal treatment duration or frequency for application of ice,45 we followed common clinical practice of icing for 20 minutes for a minimum of 3 times daily but no more than once every hour to allow skin temperature to return to normal. During this phase, early mobility was achieved using passive and active range of motion exercises, such as ankle pumps in plantarflexion and dorsiflexion, ankle circles, and calf stretches.46 The participants completed the VAS and BRUMS every other rehabilitation session.

When the participant had pain-free range of motion, they were progressed into the strength-training phase. We used a common clinical strengthening protocol consisting of basic 4-way ankle movements with resistive elastic band in plantar flexion, dorsiflexion, inversion, and eversion. Exercise protocol was similar to that in previous literature,13,47,48 and frequency of treatment during these stages was 3 to 5 days per week. At the start of the strength-training phase, the clinician completed the RAdMAT. The participant rerated the I-PRRS and continued to complete the VAS and BRUMS every other rehabilitation session.

Balance Training Phase

Once the participants were able to fully weight-bear in bilateral stance without pain, they progressed to the balance training phase. This is the point where the treatment diverged; participant A completed the AVG balance training (AVG participant) and participant B completed the TRAD balance training (TRAD participant). Both participants completed progressively challenging balance exercises of similar dosage and duration (5–7 min) in addition to 15 to 20 minutes of exercises from the strength-training phase. The exercises were completed 4 to 5 times per week for 4 weeks. At the start of the balance phase, the clinician administered the BESS and SEBT for the participants’ baseline and completed the RAdMAT. The participant rerated the FAAM, FAAM-S, and I-PRRS and continued to complete the VAS and BRUMS every other rehabilitation session. In addition, the BESS, SEBT, FAAM, and FAAM-S were also administered at week 2 and week 4 during the 4-week balance training phase.

AVG Balance Training

We used the Microsoft Xbox 360 (Redmond, WA) with Kinect sensor as a platform for the AVG balance training intervention. To ensure familiarity with the gaming console, its motion-based in-game navigation, the demands/objectives of the games to be played, orientation to the gaming system, and without performing a SLS while playing, the participants were able to familiarize themselves with the gaming system during the strength-training phase of the rehabilitation that had no balance training activities. This allowed the participant to concentrate on balance during the game-related proprioceptive challenges instead of on how to play the game.

The novelty of the AVG intervention was that in lieu of completing traditional progressively challenging balancing exercises (eg, stable surface, unstable surface, and eyes open/closed), the participant played the AVG while balancing on the injured leg. Progression of difficulty occurred because different games were classified as low, moderate, and advanced exercises based on the proprioceptive balance demands of the game (see Table 1 for more details). The clinician would determine which level of exercise was appropriate for the participant; however, participant could choose between different games, provided they were of the same difficulty level.

Table 1

Details of Games for the AVG Balance Training Participant

Games (full game)PurposeDifficultyDescription
Downhill Dodge (Kinect Sports Season 2)Weight shiftingLowPlayer skis downhill avoiding barriers by leaning to the left or right, squatting, or jumping.
Skiing (Kinect Sports Season 2)Weight shiftingLowSlalom-style downhill skiing. Player must shift weight from left to right navigate through gates. Maps have 2–3 jumps per round that can be skipped.
Bowling (Kinect Sports Season 1)Balance trainingLowBasic 10-frame bowling game. Players may take traditional bowling step or remain stationary and only use arm swing as in single-leg stance.
Pop Darts (Kinect Sports Season 2)Balance trainingLowPop balloons by throwing darts at them. Pop as many balloons as possible in 30 s. Time bonuses can extend rounds to 45 s. To be performed in single-leg stance.
Body Ball (Kinect Sports Season 1)Balance trainingModerateComputer serves balls and tells player to hit ball with head, hands, or feet. No time limit on rounds. Continues until player misses 3 balls. To be performed in single-leg stance.
Paddle Panic (Kinect Sports Season 1)Balance trainingModerateBased on table tennis. Computer continuously sends balls that the player must return. Player can return balls with either hand. Rounds are 45 s plus any time bonuses. Five balls returned in a row achieve a 2-s bonus. To be performed in single-leg stance.
Pin Rush (Kinect Sports Season 1)Balance trainingModerateBowling challenge to knock down as many pins as possible in 60 s plus any time bonuses; 5-s time bonuses achieved for every 30 pins knocked down. Player may throw balls continuously with both hands. To be performed in single-leg stance.
Smash Alley (Kinect Sports Season 2)Balance trainingModerateTennis-based challenge. Player must hit as many mascots as possible in 30 s. Receive a 10-s bonus for clearing all mascots. To be performed in single-leg stance.
Super Saver (Kinect Sports Season 1)Balance trainingModerateSoccer goalkeeper challenge in a penalty kick setting. Stop as many shots as possible until 3 missed attempts. Round has no time limit. To be performed in single-leg stance.
Tennis (Kinect Sports Season 2)Balance trainingModerateBasic tennis match. To be performed in single-leg stance. Players may be in bilateral stance between points to avoid fatigue.
Fruit Ninja Arcade Mode (Fruit Ninja)Balance trainingAdvancedSlicing fruit that flies through the air while avoiding bombs. Slice fruit with fast arm swings. Rounds last 60 s. To be performed in single-leg stance.
Rally Ball (Kinect Adventures)Balance trainingAdvancedHit a ball down a hallway to break bricks. Hit the ball with any part of your body, as it bounces back to the player. To be performed in single-leg stance.
Target Kick (Kinect Sports Season 1)Balance trainingAdvancedSoccer penalty kick-style challenge kicking the ball to targets within the goal while a goalkeeper defends. Rounds last a minimum 40 s with time bonuses available. To be played in SLS.
River Rush (Kinect Adventures)Lateral movementLowPlayer must navigate a raft down a river by stepping to the right or left and jumping while collecting as many coins as possible. Each map has multiple paths.
Reflex Ridge (Kinect Adventures)Lateral movementModerateTravel down railroad tracks while collecting coins and avoiding barriers by stepping left or right, squatting and jumping. Levels may last >3 min depending on difficulty.
Bump Bash (Kinect Sports Season 1)Lateral movementModerateVolleyball-based challenge in which player dodges objects being hit to them by quickly stepping left or right or squatting. Round continues until player is hit 3 times.
Soccer (Kinect Sports Season 1)Return to play imageryModerateSoccer game lasting 5 min. While on offense player must quickly decide where to pass the ball before the defense steals it. Defensively, players must try to deflect passes by stepping into the passing lane. Automatically switches to goal keeper when opponent gets close to the goal.

TRAD Balance Training

In the TRAD balance training protocol, participants performed conventional balance exercises in SLS similar to balance exercises performed in previous literature.43 They also completed lateral movement and plyometric exercises as outlined in Table 2. The clinician would determine which level of exercise was appropriate for the participant. Following the participants’ ability to jog without pain, both participants received functional training, which consisted of sport-specific exercises (eg, running, cutting, stopping, and a range of lateral movements) to further ready the injured athletes to return to their sport. Upon unrestricted return to sport, the clinician rerated the RAdMAT, and the participant completed the FAAM, FAAM-S, and I-PRRS.

Table 2

Balance and Lateral Movement Exercises for the TRAD Balance Training Participant

ExercisePurposeDifficultyDescription
Single-leg balance, stable surfaceBalance trainingLowPerforms single-leg stance with eyes open on involved limb on flat ground
Single-leg balance, unstable surfaceBalance trainingLowPerforms single-leg stance with eyes open on involved limb on AIREX® foam pad
Single-leg balance with eyes closed, stable surfaceBalance trainingModeratePerforms single-leg stance with eyes closed on involved limb on flat ground
Single-leg balance, stable surface with ball tossBalance trainingModeratePerforms single-leg stance on involved limb on flat ground while tossing a ball to the clinician
Single-leg balance, unstable surface with ball tossBalance trainingModeratePerforms single-leg stance on involved limb on AIREX® foam pad while tossing a ball to the clinician
Single-leg balance with eyes closed, unstable surfaceBalance trainingAdvancedPerforms single-leg stance with eyes closed on involved limb on AIREX® foam pad
Single-leg balance, Bosu ball with ball tossBalance trainingAdvancedPerforms single-leg stance on involved limb on AIREX® foam pad while tossing a ball to the clinician.
Lateral shuffleLateral movementLowLateral movement exercise to reintroduce cutting to the involved limb
CariocaLateral movementLowLateral movement exercise to reintroduce cutting to the involved limb
Bilateral-leg plyometric line jumpLateral movementModeratePerforms jumps over a line with 2 legs, both forward and backward, as well as side to side
Single-leg plyometric line jumpsLateral movementAdvancedPerforms jumps over a line with the involved leg only, both forward and backward, as well as side to side

Analysis

We analyzed the data using relevant descriptive statistical analyses to describe the differences in functional outcomes and psychological responses for both participants during the rehabilitation process.

Results

The AVG Participant

Balance

The AVG participant experienced a rehabilitation setback following her initial return to play early in the balance training phase. Her original baseline balance measures prior to the setback, on the fourth day of data collection, were subsequently discarded. Despite this setback, when the BESS score was 5.5, during the course of the balance intervention, the AVG participant’s BESS scores improved from the initial 3 errors to 2 errors. As shown in Figure 2, similar to the BESS scores, the AVG participant also saw improvements in dynamic balance in all 3 directions of the SEBT throughout the course of the balance training phase. She exhibited a substantially greater increase in the posteromedial reach condition (48% of limb length) than in the anterior (19%) or posterolateral (11%) directions.

Figure 2
Figure 2

—AVG participant’s SEBT reach distances at the start, midway point, and completion of the balance training phase. ANT indicates anterior; AVG, active video games; PL, posterolateral; PM, posteromedial; SEBT, Star Excursion Balance Test.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Rehabilitation Adherence

Descriptive statistical analyses revealed that the AVG participant’s clinician-rated adherence to the rehabilitation remained relatively stable and high throughout the rehabilitation protocol (mean [SD] = 55.57 [1.90]; R = 54–59; out of possible 64). More specifically, after restarting the balance training protocol following the initial setback, her adherence was rated as 57 and at the end of the rehabilitation protocol, her adherence was rated as 56, indicating high adherence to the rehabilitation.39,49

Foot And Ankle Ability

The AVG participant reported relatively low ankle functional ability at baseline on both the FAAM (12%) and FAAM-S (0%) scales as depicted in Figure 3. These scores consistently increased throughout the duration of the rehabilitation, aside from the setback between the sixth and seventh days of data collection, and were substantially higher by the completion of the balance training phase.

Figure 3
Figure 3

—FAAM and FAAM-S results in the AVG participant. Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 11—participant restarted the balance training phase. AVG indicates active video games; FAAM, Foot and Ankle Ability Measure; FAAM-S, Foot and Ankle Ability Measure-Sports.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Pain

The AVG participant exhibited a moderately high level of pain following the injury, which decreased substantially with treatment during the acute care phase (see Figure 4). She sustained her setback between data points 6 and 7, where a substantial increase in pain was observed. Pain levels decreased quickly with treatment and decreased more following the resumption of the balance training phase but later began to increase toward the end of this balance training phase.

Figure 4
Figure 4

—VAS for pain in the AVG participant. Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 6—participant to return to full play the next day. Data point 7—first data collection following participant’s setback. Data point 11—participant restarted the balance training phase. AVG indicates active video games; VAS, Visual Analog Scale.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Mood

Scores from the BRUMS were separated into individual subscales as shown in Figure 5. At the start of the rehabilitation, the following self-reported mood state scores were observed: scores for confusion were reported within the normal range (0–3), scores for anger and tension fluctuated between normal (0–3) and cautionary ranges (4–8), scores for depression (score range: 3–7) and fatigue (score range: 7–13) were reported within the cautionary range, and score for vigor within the follow-up range (less than 6).44,50 Following the rehabilitation setback (between data points 6 and 7), all mood states except for fatigue were reported at the range requiring follow-up.50 Soon after starting the balance training protocol (data point 12), the self-reported scores for anger, confusion, and depression normalized to zero. The scores for fatigue and tension fluctuated during the balance training protocol, indicating some increased cause for concern.50 The AVG participant’s vigor scores remained constantly within the follow-up range50 throughout the rehabilitation protocol.

Figure 5
Figure 5

—BRUMS for AVG participant. Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 6—participant to return to full play the next day. Data point 7—first data collection following participant’s setback. Data point 11—participant restarted the balance training phase. AVG indicates active video games; BRUMS, Brunel Mood Scale.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Psychological Readiness to Return to Sport

Descriptive statistical analyses revealed that the AVG participant’s perceived psychological readiness to return to sport fluctuated during the rehabilitation (mean [SD] = 26.75 [19.03]). As shown in Figure 6, initially, the participant reported as having low readiness to return to sport (score 39 out of 60) on returning to competitive play. Following the rehabilitation setback, the participant’s reported confidence was 31, then decreased to 12 (data points 10 and 11). However, on completion of the balance training protocol, her self-reported readiness to return to sport was 50, which is considered to be within the score range where an athlete can be considered to be psychologically ready to return to sport.21

Figure 6
Figure 6

—Injury-Psychological Readiness to Return to Sport results in the AVG participant (max score = 60). Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 5—prior to participant returning to play. Data point 11—participant restarted the balance training phase. AVG indicates active video games.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

The TRAD Participant

Balance

The TRAD participant’s static balance changes from the BESS showed modest improvement with a decrease of 2 errors (initial BESS score 12 decreased to 10) over the course of the balance training phase. The TRAD participant also saw improvements in dynamic balance in all 3 directions of the SEBT (Figure 7). The TRAD participant exhibited increases in both the posteromedial (16%) and anterior (20%) reach conditions but only had a modest improvement in the posterolateral directions (8%).

Figure 7
Figure 7

—TRAD balance exercises participant’s SEBT reach distances at the start, midway point, and completion of the balance training phase. ANT indicates anterior; PL, posterolateral; PM, posteromedial; SEBT, Star Excursion Balance Test; TRAD, traditional.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Rehabilitation Adherence

Descriptive statistical analyses revealed that the TRAD participant’s clinician-rated adherence to the rehabilitation remained relatively stable and moderate throughout the rehabilitation protocol (mean [SD] = 47.25 [2.22]; R = 45–50; out of possible 64). At the start of the overall rehabilitation, her clinician-rated adherence was 50. At the beginning of the balance training protocol, her adherence was rated as 48 and at the end of the rehabilitation protocol, her adherence had decreased to 46, indicating moderate levels of adherence.39,49

Foot And Ankle Function

Self-reported ankle function through the FAAM and FAAM-S scales at the time of injury was 56% and 9%, respectively (Figure 8). The TRAD participant showed a substantial increase in function midway through the balance training phase, continuing to improve through the end of the phase in the FAAM and FAAM-S scales.

Figure 8
Figure 8

—FAAM and FAAM-S results in the TRAD balance exercises participant. Data point of note: Data point 3—participant started the balance training phase. FAAM indicates Foot and Ankle Ability Measure; FAAM-S, Foot and Ankle Ability Measure-Sports; TRAD, traditional.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Pain

The TRAD participant reported only mild pain following the onset of her injury but over the course of her rehabilitation noted varying levels of pain (Figure 9). These pain levels were through a relatively small range on the VAS (2–20 mm).

Figure 9
Figure 9

—VAS for pain in the TRAD balance exercises participant. Data point of note: Data point 3—participant started the balance training phase. TRAD indicates traditional; VAS, Visual Analog Scale.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Mood

Scores from the BRUMS for the TRAD participant were separated into individual subscales (Figure 10). At the start of the rehabilitation, the following self-reported mood state scores were observed: scores for confusion were within the normal range (0–3), whereas anger, depression, and tension were within the cautionary range (4–8). Both fatigue (16) and vigor (2) were within the range that require follow-up.44,50 Although the participant’s mood appeared to improve overall as the rehabilitation progressed, most mood states (anger, depression, fatigue, and tension) appeared to fluctuate between normal and cautionary ranges throughout the rehabilitation, indicating some increased cause for concern.50 The TRAD participant’s vigor scores remained constantly within the follow-up range50 throughout the rehabilitation protocol.

Figure 10
Figure 10

—BRUMS for TRAD balance exercises participant. Data point of note: Data point 3—participant started the balance training phase. BRUMS indicates Brunel Mood Scale; TRAD, traditional.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Psychological Readiness to Return to Sport

Descriptive statistical analyses revealed that the TRAD participant’s perceived psychological readiness to return to sport steadily increased as the rehabilitation progressed (mean [SD] = 28.00 [22.42]). As shown in Figure 11, initially, the participant reported having very low readiness to return to sport (score 5 out of 60). At the beginning of the balance training phase, her self-reported readiness to return to sport score was 15 and on completion of the balance training phase, the score was 55, which is considered to be within the score range where an athlete can be considered to be psychologically ready to return to sport.21

Figure 11
Figure 11

—Injury-Psychological Readiness to Return to Sport results in the TRAD balance exercises participants (max score = 60). Data point of note: Data point 3—participant started the balance training phase. TRAD indicates traditional.

Citation: Journal of Sport Rehabilitation 29, 2; 10.1123/jsr.2017-0135

Discussion

The purpose of the current study was to describe the functional outcomes and psychological benefits of using AVG in the rehabilitation of acute LAS. Overall, the results from the 2 cases revealed that the 2 balance training protocols (AVG and TRAD) were effective in restoring patient’s balance to functional levels. More specifically, both objective measures (BESS and SEBT) and subjective measures (FAAM and FAAM-S) suggested that despite the AVG participant experiencing more severe LAS and a setback during the injury rehabilitation, both participants reported good foot and ankle function at the end of the rehabilitation protocol. Moreover, the improvements in foot and ankle function for both AVG and TRAD participants were well over the minimum clinically important difference.40

The results obtained are promising. If AVG as a treatment modality for balance training is able to provide similar functional outcomes as traditional rehabilitation exercises, it has the potential to provide more versatility into the static and dynamic postural control exercises typically used following acute LAS. The current results are also similar to those found in previous research.35 Although Vernadakis et al35 did not directly make comparisons between the Xbox Kinect group and the TRAD balance exercise group, when looking at the mean scores, they too find comparable improvements in balance ability between the 2 experimental groups. However, as their study used a retrospective design with previously injured athletes, their results may not be directly comparable with our findings, warranting further research. Given the apparent variance between our 2 participants (ie, injury severity and a number of psychosocial differences that will be discussed later), making direct comparisons between the 2 protocols used might also be misleading. Without previous research to compare with, the functional gains observed could have been a result of the AVG intervention, or simply a result of that particular athlete’s natural healing process, or a combination of both factors.

In addition to the positive functional outcomes, it appeared that the AVG intervention had a positive effect on the participant’s adherence to the rehabilitation (behavior). Despite reporting high to moderate levels of pain throughout the rehabilitation and experiencing a setback in her rehabilitation, the AVG participant’s adherence to the rehabilitation was continually reported as high by the clinician, with a slight increase in scores following the start of the AVG intervention. This is somewhat unusual, as many clinicians are typically reporting suboptimal levels of adherence, typically ranging from 40% to 91%.51 More specifically, adherence is often higher at the start of the rehabilitation52 and then decreasing as the rehabilitation progresses, as was found to be the case with the TRAD participant in this study.

Despite the aforementioned statistics, the increase in adherence during the AVG intervention may not be surprising. Existing research has suggested that by creating variability in rehabilitation exercises,17,18 increasing athletes’ perceived control over their rehabilitation process,53 and providing the athlete a sense of autonomy,54 such as empowering them to choose their own games to play during rehabilitation, it is possible to achieve a positive effect on athlete’s adherence to the rehabilitation, and as a result also improve their overall rehabilitation outcomes.53,54 Thus, the findings from our AVG case study are promising, as research has indicated that patients with high adherence typically experience 26% better treatment outcomes than those who do not adhere well.55

Thus far, no empirical investigations into effects of AVG on rehabilitation adherence have been conducted with athletic populations.32 It is known that using AVG as a modality for preventative musculoskeletal injury interventions among elderly27 and as part of a cardiovascular exercise intervention with adults56 have resulted in increased adherence. Given the vast differences in study population, aim of the intervention, and the actual AVG used, future research is certainly warranted before any conclusions about the effectiveness of AVG on rehabilitation adherence can be made.

The results also suggest that the AVG intervention may have had a positive influence on the participant’s mood (affect). Initially, the AVG participant reported anger, confusion, depression, fatigue, and tension scores considered to be within either the normal or cautionary range.50 Following the rehabilitation setback and on starting the AVG intervention, with the exception of confusion, all negative mood scores changed to a level requiring follow-up.50 However, on starting the AVG intervention, all of the negative mood states quickly returned back to the normal level, and the participant reported very little or no anger, confusion, or depression during the whole duration of the AVG intervention.

Given that the AVG participant received no psychological intervention during her rehabilitation, these results are worthy of noting. Although it is likely that physical progress (eg, moving from one rehabilitation phase to the other) elicited positive changes in mood, it is also possible that the relatively quick change in negative mood states from follow-up to normal levels was not solely a result of physical progress. Previous research with injured athletes has suggested that a range of personal, situational, and injury-related factors also influence athletes’ mood and other emotional responses.57,58 Therefore, it is likely that AVG intervention (ie, novel treatment modality, a situational factor) may have been 1 factor affecting the recorded positive changes in the participant’s mood.

Both empirical and anecdotal evidence on the effects of AVG on mood and emotional states is equivocal.32 Two studies conducted with the elderly59,60 have found AVG as having positive effects on the participant’s mood. By contrast, a study that aimed to compare the efficiency of traditional and video game–based balance training intervention among adults found no significant differences in participant’s mood preintervention and postintervention, regardless of the intervention.61 As the aforementioned studies vary greatly in research design and methodology, future research is certainly warranted before any conclusions about the effectiveness of AVG on individual athlete’s mood states can be made.

Besides the potential positive effects of AVG on mood, the reported mood states in general by both participants are worthy of further discussion. Consistent with existing literature,62 both participants reported fluctuating negative mood states throughout the rehabilitation. They both also reported consistently low vigor scores across the whole rehabilitation, at the level that warrants follow-up.50 Vigor has been found to be a significant predictor of faster recovery among elite injured athletes,63 and when combined with negative mood states, low vigor has been associated with poor mental health.64 Moreover, the aforementioned negative mood states have also been found to be correlated with orthopedic incidents, with each mood dimension explaining 6% to 7% of the variance.65 Based on the these results, practitioners working with injured athletes should monitor injured athlete’s mood states throughout the rehabilitation to minimize the risk of injury (or reinjury) and to ensure appropriate biopsychosocial return to sport decisions.

We also monitored both participants’ perceived confidence in returning back to sport (I-PRRS scores) throughout the rehabilitation. Initially, both participants, expectedly, reported very low I-PRRS scores and at the end of the rehabilitation protocol, both reported I-PPRS scores at a level ranging from 50 to 60 where an athlete is considered to be psychologically ready to return to sport.21 However, what was interesting was the ways in which the I-PRRS scores fluctuated during the rehabilitation for the AVG participant. The AVG participant’s setback occurred following her initial return to full participation, when, immediately prior, her reported I-PRRS score was 39. Although no real clinical cutoff points for the I-PRRS have been established in the literature, at the time of her first attempt to return to activity, her score was well below the currently recommended minimum score.21

More specifically, when examining AVG participant’s I-PRRS and BRUMS scores immediately prior to returning to sport for the first time (before setback) collectively, the results raise an interesting and important point. Despite being functionally considered to be ready to return to participation, few notable psychological changes emerged: Immediately before returning to participation, AVG participant’s self-reported level of depression and fatigue decreased from what was previously within the follow-up range to either normal or zero, a change that could be considered as unusually quick. Simultaneously, her self-reported tension levels increased from normal to cautionary. When coupled with continually low levels of vigor and low perceived confidence to return to sport, it could be argued that psychologically, the participant was not ready to return. It appeared that the AVG participant was very motivated to return to sport, so much so that she was willing to “ignore” possible signs of somatic anxiety (ie, increased tension). This increase in tension may or may not have resulted from increased worry about her own perceived lack of confidence in returning back to sport. As existing literature has (1) identified the absence of anxiety and fear, and the presence of confidence and motivation, as the most common prospective psychological characteristics determining athlete’s readiness to return to sport,62 yet also (2) highlighted a lack of consensus on what is psychological readiness to return to sport,62 further research is certainly warranted to better understand the interaction between functional and psychosocial readiness to return to sport.

In addition to these findings, the conceptual and theoretical merits of this study are worth noting. By adopting a case report design, the researchers were able to delve into each case in great detail and look for emergent biopsychosocial patterns within and between the participant cases. The results revealed that for both participants, their psychological responses (BRUMS and I-PRRS) and perceived pain (VAS) were closely linked with objective (BESS and SEBT) and subjective (FAAM and FAAM-S) functional measures of progress. Both participants progressed through their rehabilitation in very personal and unique ways, thus supporting existing psychological66 and biopsychosocial22 theoretical conceptualizations of athlete’s responses to injuries and rehabilitation process. Furthermore, the results supported the role of a number of personal (eg, injury history/severity, self-perceptions, mood states) and situational (eg, playing status, playing time history) factors in influencing the participants’ psychological responses to injuries.66

The psychological changes experienced by the AVG participant due to the physical setback also highlight the important relationship between psychological factors and intermediate biopsychosocial recovery outcomes as outlined by Brewer et al22 in their biopsychosocial model of sport injury rehabilitation. More specifically, the setback in rehabilitation elicited negative changes in mood (emotional response) and decrease in perceived readiness to return to activity (cognitive appraisal). However, she did remain highly adherent (behavioral response) to the rehabilitation, despite knowing that her return to sport would be delayed. It is likely that her continued motivation to adhere to rehabilitation was influenced by a number of personal and situations factors. For example, injury severity (grade II LAS), injury history (2 previous LAS), playing status (junior), history of playing time in games (regular minutes), and timing of the season (end of competitive season) were all likely to influence a participant’s perceptions of pain, rate of recovery, and readiness to return to sport appraisals, which in turn would have influenced the AVG participant’s overall mood and adherence and desire to return back to sport to ensure she can play during the conference and national tournaments. It is also likely that similar personal and situational factors also played a role in the TRAD participant’s motivation to adhere to rehabilitation. Although her injury was less severe (grade I LAS), and she also had previous experiences of LAS rehabilitation (1 previous LAS), her playing status (freshman), history or playing time in games (irregular minutes), and timing of the season (off-season workouts) were all likely to influence the perceived urgency and need to return back to sport. To what extent this was the case for either of the participants warrants further research.

This study also had multiple limitations that must be taken into consideration when interpreting the results. First, although using the case report design was one of the study’s strengths, it is also one of its weaknesses. Having participants who encountered LAS of varying severity, with different demographic backgrounds (ie, playing position/status, years of college playing experience, injury history, sporting background), we were unable to compare the 2 cases. As such, it is unclear if the observed functional outcomes and psychological benefits of the AVG intervention were indeed purely a result of the AVG intervention or something else. Second, the small sample size itself indicates lack of generalizability of the findings. Third, given the acute nature of the injuries, the rehabilitation process for the participants varied. As such, the intervention itself varied to ensure ethical and patient-centered care for both participants, further emphasizing the lack of generalizability of the results.

Nevertheless, this current study adds to the existing literature in number of ways. As both participants, regardless of LAS severity, reported similar levels of ankle function at the end of the rehabilitation protocol, our results highlight the potential usefulness of using AVG as an alternative treatment modality for LAS balance training. Coupled with the positive changes in mood and continued high adherence during the AVG intervention, AVG could be a useful modality both functionally and psychologically. Sport medicine professionals have identified creating variability in treatment exercises as the most popular way to facilitate successful rehabilitation and coping,17,18,25,26 and as successful rehabilitation is usually characterized by athlete’s ability to remain positive and having high levels of adherence,17,18,25,26 using AVG-based treatment activities have the potential to be useful, perhaps more so in home-based exercises and with younger populations.32

References

  • 1.

    Agel J, Palmieri-Smith RM, Dick R, Wojtys EM, Marshall SW. Descriptive epidemiology of collegiate women’s volleyball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004. J Athl Train. 2007;42(2):295302. PubMed ID: 17710179

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Aoki H, O’Hata N, Kohno T, Morikawa T, Seki J. A 15-year prospective epidemiological account of acute traumatic injuries during official professional soccer league matches in Japan. Am J Sports Med. 2012;40(5):10061014. PubMed ID: 22408048 doi:10.1177/0363546512438695

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37(1):7394. PubMed ID: 17190537 doi:10.2165/00007256-200737010-00006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Fousekis K, Tsepis E, Vagenas G. Intrinsic risk factors of noncontact ankle sprains in soccer: a prospective study on 100 professional players. Am J Sports Med. 2012;40(8):18421850. PubMed ID: 22700889 doi:10.1177/0363546512449602

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Michelson J, Hutchins C. Mechanoreceptors in human ankle ligaments. J Bone Joint Surg Br. 1995;77(2):219224.

  • 6.

    Hamson-Utley JJ, Martin S, Walters J. Athletic trainers’ and physical therapists’ perceptions of the effectiveness of psychological skills within sport injury rehabilitation programs. J Athl Train. 2008;43(3):258264. PubMed ID: 18523575 doi:10.4085/1062-6050-43.3.258

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Kamphoff C, Hamson-Utley JJ, Antoine B, Knutson B, Thomae J, Hoenig C. Athletic training students’ perceptions of the importance and effectiveness of psychological skills within sport injury rehabilitation. Athl Train Educ J. 2010;5(3):109116.

    • Search Google Scholar
    • Export Citation
  • 8.

    Arvinen-Barrow M, Penny G, Hemmings B, Corr S. UK chartered physiotherapists’ personal experiences in using psychological interventions with injured athletes: an interpretative phenomenological analysis. Psychol Sport Exerc. 2010;11(1):5866. doi:10.1016/j.psychsport.2009.05.004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Taylor J, Stone KR, Mullin MJ, Ellenbecker T, Walgenbach A. Comprehensive Sports Injury Management: From Examination of Injury to Return to Sport. 2nd ed. Austin, TX: Pro-Ed; 2003.

    • Search Google Scholar
    • Export Citation
  • 10.

    Renström PA, Konradsen L. Ankle ligament injuries. Br J Sports Med. 1997;31(1):1120. doi:10.1136/bjsm.31.1.11

  • 11.

    Matharu GS, Najran PS, Porter KM. Soft-tissue ankle injuries. Trauma. 2010;12(2):105115. doi:10.1177/1460408610367967

  • 12.

    Collado H, Coudreuse JM, Graziani F, Bensoussan L, Viton JM, Delarque A. Eccentric reinforcement of the ankle evertor muscles after lateral ankle sprain. Scand J Med Sci Sports. 2010;20(2):241246. PubMed ID: 19486488 doi:10.1111/j.1600-0838.2009.00882.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010;29(1):157167. PubMed ID: 19945591 doi:10.1016/j.csm.2009.09.006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Han K, Ricard MD. Effects of 4 weeks of elastic-resistance training on ankle-evertor strength and latency. J Sport Rehabil. 2011;20(2):157173. PubMed ID: 21576708 doi:10.1123/jsr.20.2.157

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Bassett SF, Prapavessis H. Home-based physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains. Phys Ther. 2007;87(9):11321143. PubMed ID: 17609331 doi:10.2522/ptj.20060260

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce injuries in youth soccer: a cluster-randomised controlled trial. Br J Sports Med. 2010;44(8):555562. PubMed ID: 20547668 doi:10.1136/bjsm.2010.074377

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Arvinen-Barrow M, Hemmings B, Weigand DA, Becker CA, Booth L. Views of chartered physiotherapists on the psychological content of their practice: a national follow-up survey in the United Kingdom. J Sport Rehabil. 2007;16:111121. PubMed ID: 17918698 doi:10.1123/jsr.16.2.111

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    Clement D, Granquist MD, Arvinen-Barrow M. Psychosocial aspects of athletic injuries as perceived by athletic trainers. J Athl Train. 2013;48(4):512521. PubMed ID: 23724772 doi:10.4085/1062-6050-48.3.21

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Brewer BW. Psychology of sport injury rehabilitation. In: Tenenbaum G, Eklund RC, eds. Handbook of Sport Psychology. 3rd ed. New York, NY: Wiley; 2007:404424.

    • Search Google Scholar
    • Export Citation
  • 20.

    Ardern C, Taylor N, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med. 2013;47(17):11201126. PubMed ID: 23064083 doi:10.1136/bjsports-2012-091203

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Glazer DD. Development and preliminary validation and the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. J Athl Train. 2009;44:185189. PubMed ID: 19295964 doi:10.4085/1062-6050-44.2.185

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Brewer BW, Andersen MB, Van Raalte JL. Psychological aspects of sport injury rehabilitation: toward a biopsychological approach. In: Mostofsky DL, Zaichkowsky LD, eds. Medical Aspects of Sport and Exercise. Morgantown, WV: Fitness Information Technology; 2002:4154.

    • Search Google Scholar
    • Export Citation
  • 23.

    DePalma MT, DePalma B. The use of instruction and the behavioural approach to facilitate injury recovery. Athl Train. 1989;24:217219.

    • Search Google Scholar
    • Export Citation
  • 24.

    Arvinen-Barrow M, Massey WV, Hemmings B. Role of sport medicine professionals in addressing psychosocial aspects of sport-injury rehabilitation: professional athletes’ views. J Athl Train. 2014;49(6):764772. PubMed ID: 25243737 doi:10.4085/1062-6050-49.3.44

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Hemmings B, Povey L. Views of chartered physiotherapists on the psychological content of their practice: a preliminary study in the United Kingdom. Br J Sports Med. 2002;36(1):6164. PubMed ID: 11867495 doi:10.1136/bjsm.36.1.61

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Heaney C. Physiotherapists’ perceptions of sport psychology intervention in professional soccer. Int J Sport Exerc Psychol. 2006;4(1):7386. doi:10.1080/1612197X.2006.9671785

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Bell CS, Fain E, Daub J, et al. Effects of Nintendo Wii on quality of life, social relationships, and confidence to prevent falls. Phys Occup Ther Geriatr. 2011;29(3):213221. doi:10.3109/02703181.2011.559307

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Celinder D, Peoples H. Stroke patients’ experiences with Wii Sports® during inpatient rehabilitation. Scand J Occup Ther. 2012;19(5):457463. PubMed ID: 22339207 doi:10.3109/11038128.2012.655307

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Hsu JK, Thibodeau R, Wong SJ, Zukiwsky D, Cecile S, Walton DM. A “Wii” bit of fun: the effects of adding Nintendo Wii® Bowling to a standard exercise regimen for residents of long-term care with upper extremity dysfunction. Physiother Theor Pract. 2011;27(3):185193. doi:10.3109/09593985.2010.483267

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Baltaci G, Harput G, Haksever B, Ulusoy B, Ozer H. Comparison between Nintendo Wii Fit and conventional rehabilitation on functional performance outcomes after hamstring anterior cruciate ligament reconstruction: prospective, randomized, controlled, double-blind clinical trial. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):880887. PubMed ID: 22543515 doi:10.1007/s00167-012-2034-2

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Fitzgerald D, Trakarnratanakul N, Smyth B, Caulfield B. Effects of a wobble board-based therapeutic exergaming system for balance training on dynamic postural stability and intrinsic motivation levels. J Orthop Sports Phys Ther. 2010;40(1):1119. doi:10.2519/jospt.2010.3121

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Arvinen-Barrow M, Manley A, Maresh N. The potential psychological benefits of active video games in the rehabilitation of musculoskeletal injuries and deficiencies: a narrative review of the literature. Phys Ther Rev. 2014;19(6):410439. doi:10.1179/1743288X14Y.0000000156

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Middlemas DA, Basilicato J, Prybicien M, Savoia J, Biodoglio J. Incorporating gaming technology into athletic injury rehabilitation: A review of the literature. Athl Train Sports Health Care. 2009;1(2):7984. doi:10.3928/19425864-20090301-06

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    Manley AJ, Arvinen-Barrow M, Wallace J. An exploration of athletes’ perceptions and experiences of active video games in relation to rehabilitation from sports injuries. Paper presented at: Division of Sport & Exercise Psychology Conference; December 16–17, 2013; Manchester, United Kingdom. https://www.slideserve.com/ansel/dsep-conference-16-17-december-2013. Accessed September 30, 2014.

    • Export Citation
  • 35.

    Vernadakis N, Derri V, Tsitskari E, Antoniou P. The effect of Xbox Kinect intervention on balance ability for previously injured young competitive male athletes: a preliminary study. Phys Ther Sport. 2014;15(3):148155. PubMed ID: 24239167 doi:10.1016/j.ptsp.2013.08.004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Barker J, McCarthy PJ, Jones MV, Moran AP. Single-Case Research Methods in Sport and Exercise Psychology. Abingdon, United Kingdom: Routledge; 2011.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37.

    Riemann BL, Guskiewicz KM, Shields EW. Relationship between clinical and forceplate measures of postural stability. J Sport Rehabil. 1999;8(2):7182. doi:10.1123/jsr.8.2.71

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339357. PubMed ID: 22892416 doi:10.4085/1062-6050-47.3.08

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39.

    Granquist MD, Gill DL, Appaneal RN. Development of a measure of rehabilitation adherence for athletic training. J Sport Rehabil. 2010;19:249267. PubMed ID: 20811076 doi:10.1123/jsr.19.3.249

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11):968983. PubMed ID: 16309613 doi:10.1177/107110070502601113

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41.

    Carcia CR, Martin RL, Drouin JM. Validity of the Foot and Ankle Ability Measure in athletes with chronic ankle instability. J Athl Train. 2008;43(2):179183. PubMed ID: 18345343 doi:10.4085/1062-6050-43.2.179

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42.

    Huskinsson EC. Measurement of pain. Lancet. 1974;304:11271131. doi:10.1016/S0140-6736(74)90884-8

  • 43.

    Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports. 1999;9(2):104109. PubMed ID: 10220845 doi:10.1111/j.1600-0838.1999.tb00217.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Terry PC, Lane AM, Fogarty GJ. Construct validity of the profile of mood states—adolescents for use with adults. Psychol Sport Exerc. 2003;4(2):125139. doi:10.1016/S1469-0292(01)00035-8

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45.

    Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):720. PubMed ID: 18298355 doi:10.1016/S0004-9514(08)70061-8

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. PubMed ID: 20457737 doi:10.1136/bmj.c1964

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2007;37(6):303311. PubMed ID: 17612356 doi:10.2519/jospt.2007.2322

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Powers ME, Buckley BD, Kaminski TW, Hubbard TJ, Ortiz C. Six weeks of strength and proprioception training does not affect muscle fatigue and static balance in functional ankle instability. J Sport Rehabil. 2004;13(3):201227. doi:10.1123/jsr.13.3.201

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49.

    Granquist MD, Brewer BW. Psychological aspects of rehabilitation adherence. In: Arvinen-Barrow M, Walker N, eds. Psychology of Sport Injury and Rehabilitation. Abingdon, United Kingdom: Routledge; 2013:4053.

    • Search Google Scholar
    • Export Citation
  • 50.

    Terry PC, Lane AM. User Guide for the Brunel Mood Scale (BRUMS)Queensland, AustraliaUniversity of Southern Queensland; 2010.

  • 51.

    Brewer BW. Adherence to sport injury rehabilitation programs. J Appl Sport Psychol. 1998;10:7082. doi:10.1080/10413209808406378

  • 52.

    Udry E. Coping and social support among injured athletes following surgery. J Sport Exerc Psychol. 1997;19(1):7190. doi:10.1123/jsep.19.1.71

  • 53.

    Tracey J. The emotional response to the injury and rehabilitation process. J Appl Sport Psychol. 2003;15(4):279293. doi:10.1080/714044197

  • 54.

    Granquist MD, Podlog L, Engel JR, Newland A. Certified athletic trainers’ perspectives on rehabilitation adherence in collegiate athletic training settings. J Sport Rehabil. 2014;23:123133. PubMed ID: 23981501 doi:10.1123/JSR.2013-0009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55.

    DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794811. PubMed ID: 12218770 doi:10.1097/00005650-200209000-00009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56.

    Annesi JJ, Mazas J. Effects of virtual reality-enhanced exercise equipment on adherence and exercise-induced feeling states. Percept Mot Skills. 1997;85:835844. PubMed ID: 9399288 doi:10.2466/pms.1997.85.3.835

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57.

    Ruddock-Hudson M, O’Halloran P, Murphy G. The psychological impact of long-term injury on Australian football league players. J Appl Sport Psychol. 2014;26:377394. doi:10.1080/10413200.2014.897269

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58.

    Clement D, Arvinen-Barrow M, Fetty T. Psychosocial responses during different phases of sport injury rehabilitation: a qualitative study. J Athl Train. 2015;50(1):95104. PubMed ID: 25322346 doi:10.4085/1062-6050-49.3.52

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59.

    Brandt K, Paniagua MA. The use of Nintendo Wii with long-term care residents. J Am Geriatr Soc. 2011;59:23932395. PubMed ID: 22188095 doi:10.1111/j.1532-5415.2011.03692.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60.

    Tsai TH, Chang HT, Huang GS, Chang CC. WaterBall: the exergaming design for rehabilitation of the elderly. Comput Aided Des Appl. 2012;9(4):481489. doi:10.3722/cadaps.2012.481-489

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 61.

    Kliem A, Wiemeyer J. Comparison of a traditional and a video game based balance training program. Int J Comput Sci Sport. 2010;9:13.

  • 62.

    Brewer BW, Redmond C. Psychology of Sport Injury. Champaign, IL: Human Kinetics; 2016.

  • 63.

    Quinn AM, Fallon BJ. Predictors of recovery time. J Sport Rehabil. 2000;9:6276. doi:10.1123/jsr.9.1.62

  • 64.

    Morgan WP. Test of champions the iceberg profile. Psychol Today. 1980;14:92.

  • 65.

    Galambos S, Terry P, Moyle G, Locke S, Lane A. Psychological predictors of injury among elite athletes. Br J Sports Med. 2005;39:351354. PubMed ID: 15911606 doi:10.1136/bjsm.2005.018440

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 66.

    Wiese-Bjornstal DM, Smith AM, Shaffer SM, Morrey MA. An integrated model of response to sport injury: psychological and sociological dynamics. J Appl Sport Psychol. 1998;10(1):4669. doi:10.1080/10413209808406377

    • Crossref
    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Arvinen-Barrow and Earl-Boehm are with Integrative Health Care & Performance Unit, Department of Kinesiology, University of Wisconsin-Milwaukee, Milwaukee, WI. Maresh is with Beloit College, Beloit, WI.

Arvinen-Barrow (arvinenb@uwm.edu) is corresponding author.
  • View in gallery

    —Flowchart of the study intervention. AROM indicates active range of motion; BESS, Balance Error Scoring System; BRUMS, Brunel Mood Scale; FAAM, Foot and Ankle Ability Measure; FAAM-S, Foot and Ankle Ability Measure-Sports; I-PRRS, Injury-Psychological Readiness to Return to Sport; RAdMAT, Rehabilitation Adherence Measure for Athletic Training; RTP, Return to play; SEBT, Star Excursion Balance Test.

  • View in gallery

    —AVG participant’s SEBT reach distances at the start, midway point, and completion of the balance training phase. ANT indicates anterior; AVG, active video games; PL, posterolateral; PM, posteromedial; SEBT, Star Excursion Balance Test.

  • View in gallery

    —FAAM and FAAM-S results in the AVG participant. Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 11—participant restarted the balance training phase. AVG indicates active video games; FAAM, Foot and Ankle Ability Measure; FAAM-S, Foot and Ankle Ability Measure-Sports.

  • View in gallery

    —VAS for pain in the AVG participant. Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 6—participant to return to full play the next day. Data point 7—first data collection following participant’s setback. Data point 11—participant restarted the balance training phase. AVG indicates active video games; VAS, Visual Analog Scale.

  • View in gallery

    —BRUMS for AVG participant. Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 6—participant to return to full play the next day. Data point 7—first data collection following participant’s setback. Data point 11—participant restarted the balance training phase. AVG indicates active video games; BRUMS, Brunel Mood Scale.

  • View in gallery

    —Injury-Psychological Readiness to Return to Sport results in the AVG participant (max score = 60). Data points of note: Data point 3—participant started the strength-training phase. Data point 4—participant started the balance training phase. Data point 5—prior to participant returning to play. Data point 11—participant restarted the balance training phase. AVG indicates active video games.

  • View in gallery

    —TRAD balance exercises participant’s SEBT reach distances at the start, midway point, and completion of the balance training phase. ANT indicates anterior; PL, posterolateral; PM, posteromedial; SEBT, Star Excursion Balance Test; TRAD, traditional.

  • View in gallery

    —FAAM and FAAM-S results in the TRAD balance exercises participant. Data point of note: Data point 3—participant started the balance training phase. FAAM indicates Foot and Ankle Ability Measure; FAAM-S, Foot and Ankle Ability Measure-Sports; TRAD, traditional.

  • View in gallery

    —VAS for pain in the TRAD balance exercises participant. Data point of note: Data point 3—participant started the balance training phase. TRAD indicates traditional; VAS, Visual Analog Scale.

  • View in gallery

    —BRUMS for TRAD balance exercises participant. Data point of note: Data point 3—participant started the balance training phase. BRUMS indicates Brunel Mood Scale; TRAD, traditional.

  • View in gallery

    —Injury-Psychological Readiness to Return to Sport results in the TRAD balance exercises participants (max score = 60). Data point of note: Data point 3—participant started the balance training phase. TRAD indicates traditional.

  • 1.

    Agel J, Palmieri-Smith RM, Dick R, Wojtys EM, Marshall SW. Descriptive epidemiology of collegiate women’s volleyball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004. J Athl Train. 2007;42(2):295302. PubMed ID: 17710179

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Aoki H, O’Hata N, Kohno T, Morikawa T, Seki J. A 15-year prospective epidemiological account of acute traumatic injuries during official professional soccer league matches in Japan. Am J Sports Med. 2012;40(5):10061014. PubMed ID: 22408048 doi:10.1177/0363546512438695

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic review on ankle injury and ankle sprain in sports. Sports Med. 2007;37(1):7394. PubMed ID: 17190537 doi:10.2165/00007256-200737010-00006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Fousekis K, Tsepis E, Vagenas G. Intrinsic risk factors of noncontact ankle sprains in soccer: a prospective study on 100 professional players. Am J Sports Med. 2012;40(8):18421850. PubMed ID: 22700889 doi:10.1177/0363546512449602

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Michelson J, Hutchins C. Mechanoreceptors in human ankle ligaments. J Bone Joint Surg Br. 1995;77(2):219224.

  • 6.

    Hamson-Utley JJ, Martin S, Walters J. Athletic trainers’ and physical therapists’ perceptions of the effectiveness of psychological skills within sport injury rehabilitation programs. J Athl Train. 2008;43(3):258264. PubMed ID: 18523575 doi:10.4085/1062-6050-43.3.258

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Kamphoff C, Hamson-Utley JJ, Antoine B, Knutson B, Thomae J, Hoenig C. Athletic training students’ perceptions of the importance and effectiveness of psychological skills within sport injury rehabilitation. Athl Train Educ J. 2010;5(3):109116.

    • Search Google Scholar
    • Export Citation
  • 8.

    Arvinen-Barrow M, Penny G, Hemmings B, Corr S. UK chartered physiotherapists’ personal experiences in using psychological interventions with injured athletes: an interpretative phenomenological analysis. Psychol Sport Exerc. 2010;11(1):5866. doi:10.1016/j.psychsport.2009.05.004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Taylor J, Stone KR, Mullin MJ, Ellenbecker T, Walgenbach A. Comprehensive Sports Injury Management: From Examination of Injury to Return to Sport. 2nd ed. Austin, TX: Pro-Ed; 2003.

    • Search Google Scholar
    • Export Citation
  • 10.

    Renström PA, Konradsen L. Ankle ligament injuries. Br J Sports Med. 1997;31(1):1120. doi:10.1136/bjsm.31.1.11

  • 11.

    Matharu GS, Najran PS, Porter KM. Soft-tissue ankle injuries. Trauma. 2010;12(2):105115. doi:10.1177/1460408610367967

  • 12.

    Collado H, Coudreuse JM, Graziani F, Bensoussan L, Viton JM, Delarque A. Eccentric reinforcement of the ankle evertor muscles after lateral ankle sprain. Scand J Med Sci Sports. 2010;20(2):241246. PubMed ID: 19486488 doi:10.1111/j.1600-0838.2009.00882.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010;29(1):157167. PubMed ID: 19945591 doi:10.1016/j.csm.2009.09.006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Han K, Ricard MD. Effects of 4 weeks of elastic-resistance training on ankle-evertor strength and latency. J Sport Rehabil. 2011;20(2):157173. PubMed ID: 21576708 doi:10.1123/jsr.20.2.157

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Bassett SF, Prapavessis H. Home-based physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains. Phys Ther. 2007;87(9):11321143. PubMed ID: 17609331 doi:10.2522/ptj.20060260

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Emery CA, Meeuwisse WH. The effectiveness of a neuromuscular prevention strategy to reduce injuries in youth soccer: a cluster-randomised controlled trial. Br J Sports Med. 2010;44(8):555562. PubMed ID: 20547668 doi:10.1136/bjsm.2010.074377

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Arvinen-Barrow M, Hemmings B, Weigand DA, Becker CA, Booth L. Views of chartered physiotherapists on the psychological content of their practice: a national follow-up survey in the United Kingdom. J Sport Rehabil. 2007;16:111121. PubMed ID: 17918698 doi:10.1123/jsr.16.2.111

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    Clement D, Granquist MD, Arvinen-Barrow M. Psychosocial aspects of athletic injuries as perceived by athletic trainers. J Athl Train. 2013;48(4):512521. PubMed ID: 23724772 doi:10.4085/1062-6050-48.3.21

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Brewer BW. Psychology of sport injury rehabilitation. In: Tenenbaum G, Eklund RC, eds. Handbook of Sport Psychology. 3rd ed. New York, NY: Wiley; 2007:404424.

    • Search Google Scholar
    • Export Citation
  • 20.

    Ardern C, Taylor N, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med. 2013;47(17):11201126. PubMed ID: 23064083 doi:10.1136/bjsports-2012-091203

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Glazer DD. Development and preliminary validation and the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. J Athl Train. 2009;44:185189. PubMed ID: 19295964 doi:10.4085/1062-6050-44.2.185

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Brewer BW, Andersen MB, Van Raalte JL. Psychological aspects of sport injury rehabilitation: toward a biopsychological approach. In: Mostofsky DL, Zaichkowsky LD, eds. Medical Aspects of Sport and Exercise. Morgantown, WV: Fitness Information Technology; 2002:4154.

    • Search Google Scholar
    • Export Citation
  • 23.

    DePalma MT, DePalma B. The use of instruction and the behavioural approach to facilitate injury recovery. Athl Train. 1989;24:217219.

    • Search Google Scholar
    • Export Citation
  • 24.

    Arvinen-Barrow M, Massey WV, Hemmings B. Role of sport medicine professionals in addressing psychosocial aspects of sport-injury rehabilitation: professional athletes’ views. J Athl Train. 2014;49(6):764772. PubMed ID: 25243737 doi:10.4085/1062-6050-49.3.44

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Hemmings B, Povey L. Views of chartered physiotherapists on the psychological content of their practice: a preliminary study in the United Kingdom. Br J Sports Med. 2002;36(1):6164. PubMed ID: 11867495 doi:10.1136/bjsm.36.1.61

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Heaney C. Physiotherapists’ perceptions of sport psychology intervention in professional soccer. Int J Sport Exerc Psychol. 2006;4(1):7386. doi:10.1080/1612197X.2006.9671785

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Bell CS, Fain E, Daub J, et al. Effects of Nintendo Wii on quality of life, social relationships, and confidence to prevent falls. Phys Occup Ther Geriatr. 2011;29(3):213221. doi:10.3109/02703181.2011.559307

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Celinder D, Peoples H. Stroke patients’ experiences with Wii Sports® during inpatient rehabilitation. Scand J Occup Ther. 2012;19(5):457463. PubMed ID: 22339207 doi:10.3109/11038128.2012.655307

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Hsu JK, Thibodeau R, Wong SJ, Zukiwsky D, Cecile S, Walton DM. A “Wii” bit of fun: the effects of adding Nintendo Wii® Bowling to a standard exercise regimen for residents of long-term care with upper extremity dysfunction. Physiother Theor Pract. 2011;27(3):185193. doi:10.3109/09593985.2010.483267

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Baltaci G, Harput G, Haksever B, Ulusoy B, Ozer H. Comparison between Nintendo Wii Fit and conventional rehabilitation on functional performance outcomes after hamstring anterior cruciate ligament reconstruction: prospective, randomized, controlled, double-blind clinical trial. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):880887. PubMed ID: 22543515 doi:10.1007/s00167-012-2034-2

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Fitzgerald D, Trakarnratanakul N, Smyth B, Caulfield B. Effects of a wobble board-based therapeutic exergaming system for balance training on dynamic postural stability and intrinsic motivation levels. J Orthop Sports Phys Ther. 2010;40(1):1119. doi:10.2519/jospt.2010.3121

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Arvinen-Barrow M, Manley A, Maresh N. The potential psychological benefits of active video games in the rehabilitation of musculoskeletal injuries and deficiencies: a narrative review of the literature. Phys Ther Rev. 2014;19(6):410439. doi:10.1179/1743288X14Y.0000000156

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Middlemas DA, Basilicato J, Prybicien M, Savoia J, Biodoglio J. Incorporating gaming technology into athletic injury rehabilitation: A review of the literature. Athl Train Sports Health Care. 2009;1(2):7984. doi:10.3928/19425864-20090301-06

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    Manley AJ, Arvinen-Barrow M, Wallace J. An exploration of athletes’ perceptions and experiences of active video games in relation to rehabilitation from sports injuries. Paper presented at: Division of Sport & Exercise Psychology Conference; December 16–17, 2013; Manchester, United Kingdom. https://www.slideserve.com/ansel/dsep-conference-16-17-december-2013. Accessed September 30, 2014.

    • Export Citation
  • 35.

    Vernadakis N, Derri V, Tsitskari E, Antoniou P. The effect of Xbox Kinect intervention on balance ability for previously injured young competitive male athletes: a preliminary study. Phys Ther Sport. 2014;15(3):148155. PubMed ID: 24239167 doi:10.1016/j.ptsp.2013.08.004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Barker J, McCarthy PJ, Jones MV, Moran AP. Single-Case Research Methods in Sport and Exercise Psychology. Abingdon, United Kingdom: Routledge; 2011.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37.

    Riemann BL, Guskiewicz KM, Shields EW. Relationship between clinical and forceplate measures of postural stability. J Sport Rehabil. 1999;8(2):7182. doi:10.1123/jsr.8.2.71

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339357. PubMed ID: 22892416 doi:10.4085/1062-6050-47.3.08

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39.

    Granquist MD, Gill DL, Appaneal RN. Development of a measure of rehabilitation adherence for athletic training. J Sport Rehabil. 2010;19:249267. PubMed ID: 20811076 doi:10.1123/jsr.19.3.249

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot Ankle Int. 2005;26(11):968983. PubMed ID: 16309613 doi:10.1177/107110070502601113

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41.

    Carcia CR, Martin RL, Drouin JM. Validity of the Foot and Ankle Ability Measure in athletes with chronic ankle instability. J Athl Train. 2008;43(2):179183. PubMed ID: 18345343 doi:10.4085/1062-6050-43.2.179

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42.

    Huskinsson EC. Measurement of pain. Lancet. 1974;304:11271131. doi:10.1016/S0140-6736(74)90884-8

  • 43.

    Holme E, Magnusson SP, Becher K, Bieler T, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports. 1999;9(2):104109. PubMed ID: 10220845 doi:10.1111/j.1600-0838.1999.tb00217.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Terry PC, Lane AM, Fogarty GJ. Construct validity of the profile of mood states—adolescents for use with adults. Psychol Sport Exerc. 2003;4(2):125139. doi:10.1016/S1469-0292(01)00035-8

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45.

    Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):720. PubMed ID: 18298355 doi:10.1016/S0004-9514(08)70061-8

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. PubMed ID: 20457737 doi:10.1136/bmj.c1964

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2007;37(6):303311. PubMed ID: 17612356 doi:10.2519/jospt.2007.2322

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Powers ME, Buckley BD, Kaminski TW, Hubbard TJ, Ortiz C. Six weeks of strength and proprioception training does not affect muscle fatigue and static balance in functional ankle instability. J Sport Rehabil. 2004;13(3):201227. doi:10.1123/jsr.13.3.201

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 49.

    Granquist MD, Brewer BW. Psychological aspects of rehabilitation adherence. In: Arvinen-Barrow M, Walker N, eds. Psychology of Sport Injury and Rehabilitation. Abingdon, United Kingdom: Routledge; 2013:4053.

    • Search Google Scholar
    • Export Citation
  • 50.

    Terry PC, Lane AM. User Guide for the Brunel Mood Scale (BRUMS)Queensland, AustraliaUniversity of Southern Queensland; 2010.

  • 51.

    Brewer BW. Adherence to sport injury rehabilitation programs. J Appl Sport Psychol. 1998;10:7082. doi:10.1080/10413209808406378

  • 52.

    Udry E. Coping and social support among injured athletes following surgery. J Sport Exerc Psychol. 1997;19(1):7190. doi:10.1123/jsep.19.1.71

  • 53.

    Tracey J. The emotional response to the injury and rehabilitation process. J Appl Sport Psychol. 2003;15(4):279293. doi:10.1080/714044197

  • 54.

    Granquist MD, Podlog L, Engel JR, Newland A. Certified athletic trainers’ perspectives on rehabilitation adherence in collegiate athletic training settings. J Sport Rehabil. 2014;23:123133. PubMed ID: 23981501 doi:10.1123/JSR.2013-0009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55.

    DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794811. PubMed ID: 12218770 doi:10.1097/00005650-200209000-00009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56.

    Annesi JJ, Mazas J. Effects of virtual reality-enhanced exercise equipment on adherence and exercise-induced feeling states. Percept Mot Skills. 1997;85:835844. PubMed ID: 9399288 doi:10.2466/pms.1997.85.3.835

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57.

    Ruddock-Hudson M, O’Halloran P, Murphy G. The psychological impact of long-term injury on Australian football league players. J Appl Sport Psychol. 2014;26:377394. doi:10.1080/10413200.2014.897269

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58.

    Clement D, Arvinen-Barrow M, Fetty T. Psychosocial responses during different phases of sport injury rehabilitation: a qualitative study. J Athl Train. 2015;50(1):95104. PubMed ID: 25322346 doi:10.4085/1062-6050-49.3.52

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59.

    Brandt K, Paniagua MA. The use of Nintendo Wii with long-term care residents. J Am Geriatr Soc. 2011;59:23932395. PubMed ID: 22188095 doi:10.1111/j.1532-5415.2011.03692.x

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60.

    Tsai TH, Chang HT, Huang GS, Chang CC. WaterBall: the exergaming design for rehabilitation of the elderly. Comput Aided Des Appl. 2012;9(4):481489. doi:10.3722/cadaps.2012.481-489

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 61.

    Kliem A, Wiemeyer J. Comparison of a traditional and a video game based balance training program. Int J Comput Sci Sport. 2010;9:13.

  • 62.

    Brewer BW, Redmond C. Psychology of Sport Injury. Champaign, IL: Human Kinetics; 2016.

  • 63.

    Quinn AM, Fallon BJ. Predictors of recovery time. J Sport Rehabil. 2000;9:6276. doi:10.1123/jsr.9.1.62

  • 64.

    Morgan WP. Test of champions the iceberg profile. Psychol Today. 1980;14:92.

  • 65.

    Galambos S, Terry P, Moyle G, Locke S, Lane A. Psychological predictors of injury among elite athletes. Br J Sports Med. 2005;39:351354. PubMed ID: 15911606 doi:10.1136/bjsm.2005.018440

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 66.

    Wiese-Bjornstal DM, Smith AM, Shaffer SM, Morrey MA. An integrated model of response to sport injury: psychological and sociological dynamics. J Appl Sport Psychol. 1998;10(1):4669. doi:10.1080/10413209808406377

    • Crossref
    • Search Google Scholar
    • Export Citation
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