Mental Toughness as a Determinant of Beliefs, Pain, and Adherence in Sport Injury Rehabilitation

J Sport Rehabil. 2006,15, 246-254 2006 Human Kinetics, Inc. Mental Toughness as a Determinant of Beliefs, Pain, and Adherence in Sport Injury Rehabilitation Andrew R. Levy, Remco C.J. Polman, Peter J. Clough, David C. Marchant, and Keith Earle Objective: To investigate the relationship between mental toughness, sport injury beliefs, pain, and adherence toward a sport injury rehabilitation program. Design: A prospective design was employed that evaluated adherence over the entire rehabilitation period. Participants: 70 patients undertaking a sport injury rehabilitation program for a tendonitis related injury. Main Outcome Measures: Adherence was measured using self report measures of clinic and home based rehabilitation alongside attendance. Results: No association was found between mental toughness and coping appraisals, although high mentally tough individuals displayed more positive threat appraisals and were better able to cope with pain than their less mentally tough counterparts. Greater attendance at rehabilitation sessions was displayed by more mentally tough individuals; however, more positive behavior during clinic rehabilitation was characterized by low mental toughness. Conclusions: Despite the benefits of being mentally tough, sports medicine providers need to be aware that a high degree of mental toughness may have negative consequences upon rehabilitation behavior and subsequently recovery outcomes. Key words: mental toughness, rehabilitation, adherence Regular physical activity has been established as a mechanism to prevent various chronic illnesses experienced in most western societies. This has led to the establishment of government initiatives that have promoted the participation of sport and physical activity. 1 Paradoxically, a consequence of engagement in such activities concerns the potential for and incidence of sustaining injury. Within the European Union, it is estimated that each year more than ten million people have a sport related injury requiring medical attention, with more than five million contacting the accident and emergency department of a hospital, the cost of which exceeds ten billion Euros. 2 Despite the intuitive appeal that athletes are compliant with rehabilitation treatment in order to recover and return to sport more rapidly, estimates reveal adherence rates with this population to be as low as 40%. 3 To address this issue, The authors are with The University of Hull, Department of Sport, Health, and Exercise Science, Hull, East Yorkshire HU6 7RX, UK. Email: A.Levy@hull.ac.uk. 246

Mental Toughness in Rehabilitation 247 previous research has identified sport injury beliefs, in the form of coping appraisals sport/threat appraisals, 4,5 and pain tolerance 6,7 to be associated with adhering to sport injury rehabilitation programs. In particular, Taylor and May 4 found coping appraisals (self-efficacy and treatment efficacy) to be related with all measures relating to home based adherence, although threat appraisals (perceived susceptibility and perceived severity) were related to only one measure of home adherence. Brewer et al 5 replicated these findings using a more homogenous injury population and using measures relevant both to clinic and home based environments. Implications from both studies suggest threat and coping appraisals may act as useful interventions to increase adherence to rehabilitation programs and thus optimally facilitate recovery. With regard to pain, Byerly et al 6 and Fields et al 7 found those individuals who are better able to tolerate pain tend to adhere more rigidly to their rehabilitation program. However, a limitation of both these studies is their use of the Rehabilitation Adherence Questionnaire (RAQ) 8 to assess pain. Brewer and colleagues 9 found weak psychometric properties regarding the RAQ and recommended a complete overhaul or abandonment of this assessment tool. Therefore, the present study employed a psychometrically more sound measure of pain, notably the Sports Inventory for Pain-15 item (SIP-15), which has recently been revised. 22 A personal factor that has received scant attention within the sport injury rehabilitation is mental toughness. This may be due to the lack of conceptual clarity and general consensus as to its definition. A recommendation put forward by Jones et al 10 contends more scientific investigation regarding the development and understanding of mental toughness is required. One such advancement has been put forward referred to as the 4Cs approach. 11 In establishing this approach, Clough and colleagues 11 attempted to seek what mental toughness meant to sport psychologists, athletes, and coaches across a variety of sports at elite level. Findings suggested the notion of mental toughness can be aligned with the concept of hardiness originally put forward by Kobasa. 12 Specifically, the 4Cs approach postulates that mental toughness is characterized by four factors 11 (1) control: a tendency to feel and act as if one is influential, (2) commitment: a tendency to involve oneself in rather than experience alienation from an encounter, (3) challenge: belief that life is changeable and to view this as an opportunity rather than a threat, (4) confi dence: a high sense of self-belief and unshakable faith concerning oneʼs ability to achieve success. Although this model has received scant attention, aspects such as control, commitment, and challenge that relate to hardiness have become an emerging area of study in sport. Recent findings suggest hardiness to act as a buffer to stress and can be related to improved performance in sport. 13 14 This may be due to hardy individuals being able to appraise stressful situations positively and are able to employ adaptive coping behaviors. 15 In terms of sport injury, hardiness has been identified as a personality characteristic within the model of stress and athletic injury; 16 however, no research to date has assessed this concept within this domain. Therefore, the aim of this study is to examine whether mental toughness, as defined by Clough et al 11, is associated with sport injury beliefs (such as threat appraisals and coping appraisals), pain and rehabilitation adherence.

248 Levy Research Design Methods This prospective study evaluated three indices of adherence, notably attendance, clinic, and home based rehabilitation over the entire rehabilitation period and correlated the findings with belief, pain, and mental toughness scores. Participants Seventy patients were recruited from four private physiotherapy clinics (44 male and 26 female), with a mean age of 32.5 years (SD = 10.2). Thirty-one percent of participants were competitive athletes and 69% were recreational athletes. All participants had a tendonitis related injury in which no prior surgery was required. The duration of the rehabilitation period undertaken by participants ranged between 8 and 10 weeks. It should be noted that none of the participants had been involved any previous rehabilitation programs. Ethical approval was obtained by The University of Hull Research Ethics Committee, alongside informal consent which was provided by all participants. Procedure In the initial stages of rehabilitation, participants completed the Sport Injury Rehabilitation Belief Survey (SIRBS), the mental toughness 18 item questionnaire (MT18), and the Sport Inventory for Pain 15 item (SIP-15). Physiotherapists measured adherence via attendance and completion of clinic rehabilitation activity using the Sport Injury Rehabilitation Adherence Survey (SIRAS). Participants were informed to record their adherence to home based rehabilitation activities. Measures Adherence. A trichotomous assessment of adherence was employed aligning with previous recommendations. 17 First, attendance to scheduled rehabilitation appointments was calculated by dividing the number of rehabilitation sessions attended by the number of rehabilitation sessions scheduled. Second, the SIRAS 18 was used to assess adherence during clinic-based rehabilitation sessions. This instrument requires the physiotherapist to evaluate the patientʼs behavior on a 5- point Likert scale regarding the intensity with which participants complete their prescribed exercises, the frequency with which participants followed instructions, and their receptiveness to changes toward the program. In addition, a self report measure of home based rehabilitation adherence, as recommended by Bassett 19 was used. This required participants to indicate on a 5 point Likert scale their efficiency in completing recommended home exercise, refraining from undertaking activity which could harm injury and home cryotherapy. Sport Injury Rehabilitation Beliefs. The SIRBS 4 is a 19-item questionnaire assessing severity, susceptibility (threat appraisals), treatment efficacy, and selfefficacy (coping appraisals). Ratings are made on a 7-point Likert-type scales

Mental Toughness in Rehabilitation 249 ranging from 1 (very strongly disagree) to 7 (very strongly agree). Suitable psychometric properties for these scales have previously been reported. 4 Pain. To assess pain SIP-15 was used, 22 which measures three factors concerning how athletes respond psychologically when in pain. These include direct coping, catastrophizing, and somatic awareness. Items are rated on a 5-point Likert scale anchored by 1 (strongly disagree) and 5 (strongly agree). Evidence regarding exploratory and confirmatory factor analysis for the revised SIP has been established. 22 Mental Toughness. MT18 11 was used to assess mental toughness. Ratings are made on 5-point Likert scales with end points ranging from 1 (strongly disagree) to 5 (strongly agree). Evidence concerning the reliability and validity for the MT18 has previously been established. 22 Statistical Analysis Means, standard deviations, and Pearson product moment correlations were conducted to examine the relationships among mental toughness and pain, sport injury rehabilitation beliefs, and rehabilitation adherence. To determine the effects of mental toughness upon sport injury beliefs, pain and adherence one way between subjects MANOVA was employed. The between subject factor, mental toughness, had three levels, which consisted of high/medium/low mental toughness groups. In order to establish where significant differences existed, follow up univariate analysis (ANOVA) alongside post hoc comparisons using Tukeyʼs HSD procedure were conducted. Normality of dependant variables was assessed using skewness and kurtosis statistics. Descriptive Statistics Results Alpha coefficients are shown along with means and standard deviations in Table 1. Only the three indices of adherence were found to have a negatively skewed distribution. To obtain a more normal distribution these values were transformed using reflect and square root transformation. Impact of Mental Toughness on Beliefs, Pain, and Adherence Multivariate analysis of variance indicated there to be a significant main effect for mental toughness: Wilksʼ lambda = 0.409, F 22, 114 = 2.92; P =.001. Follow up univariate analysis of variance revealed there to be a significant main effect for perceived susceptibility, F 2,67 = 5.72; P <. 01, and perceived severity, F 2,67 = 5.29; P <.01, relating to the three mental toughness groups. For perceived susceptibility, Tukey post hoc comparisons indicated that the mean scores for the low mental toughness group (M = 24.42, SD = 2.08) and medium mental toughness group (M = 23.57, SD = 2.49) were significantly different (P <.01 and P <.05, respectively) from the high mental toughness group (M = 21.00, SD = 5.34). For perceived severity, the mean score for the medium mental toughness group

250 Levy Table 1 Bivariate Correlations, Means, and Standard Deviations Relating to Mental Toughness, Sport Injury Beliefs, Pain and Adherence to Sport Injury Rehabilitation Construct 1 2 3 4 5 6 7 8 9 10 11 M SD 1. Mental toughness (.65) 50.44 13.32 2. Susceptibility.31* (.80) 23.01 3.83 3. Treatment efficacy.20.24* (.82) 71.21 2.46 4. Self efficacy.20.03.24* (.94) 13.36 2.69 5. Severity.30.69*.03.13 (.83) 20.10 2.62 6. Pain direct coping.43**.26*.26*.19.11 (.94) 17.53 3.55 7. Pain.32**.44**.25*.31**.34**.42** (.88) 15.46 1.79 catastrophizing 8. Pain somatic.07.10.01.34.15.15.10 (.50) 10.30 2.16 awareness 9. Clinic adherence.30*.74**.02.19.65**.08.22.11 (.93) 3.07 1.37 transformed 10. Home adherence transformed 11. Attendance transformed.28*.72*.06.04.60**.15.25*.08.72** (.93) 1.60 0.68.25*.21.46**.51**.12.43**.38.10.19.02 2.55 1.72 Note. Cronbach alphas are presented on the diagonals. Missing alphas were unobtainable. *p <.05 (two tailed) **p <.01 (two tailed).

Mental Toughness in Rehabilitation 251 (M = 21.09, SD = 1.35) was found to be significantly higher (P <.01) from the high mental toughness group (M = 18.78, SD = 3.33). Neither treatment efficacy, F 2,67 = 2.57; P =.084, or self efficacy, F 2,67 = 3.05; P =.060, had a significant effect with the three levels of mental toughness. Additionally, univariate analysis of variance concerning pain-coping, F 2,67 = 10.71; P <.001, and pain-catastrophy, F 2,67 = 5.65; P <.01, were found to have significant main effects with the three levels of mental toughness. For coping with pain, mean scores from Tukey post hoc comparisons revealed that the low (M = 15.63, SD = 2.22) and medium (M = 17.22, SD = 2.80) mental toughness groups were significantly different (P <.001 and P <.01, respectively) from the high mental toughness group (M = 19.83, SD = 4.11). Tukey post hoc comparison concerning pain catastrophy found the mean score for the low mental toughness group (M = 16.25, SD = 1.36) to be significantly different (P <.01) from the high mental toughness group (M = 14.61, SD = 1.88). Pain relating to somatic awareness, F 2,67 =.037; P =.96) was not found to be significantly different from the three mental toughness groups. Finally, univariate analysis of variance also revealed a significant main effect for clinic based rehabilitation adherence, F 2,67 = 7.56; P <.01, and attendance at rehabilitation sessions, F 2,67 = 3.24; P <.05, but not for home based rehabilitation, F 2,67 = 2.89; P =.079. Tukey post hoc comparison for clinic based adherence found mean scores for both the low (M = 288.33, SD = 63.72) and medium (M = 302.13, SD = 45.85) mental toughness groups to be significantly different (P <.01) from the high mental toughness group (M = 228.17, SD = 89.63). With regard to attendance at rehabilitation, low mentally tough individuals (M = 88.38, SD = 10.44) were found to be significantly different (P <.05) compared to the high mental toughness group (M = 94.83, SD = 7.62). Correlation Analysis Pearson product moment correlations are shown in Table 1. In terms of sport injury rehabilitation, beliefs perceived susceptibility and perceived severity were negatively associated with mental toughness. Both treatment efficacy and self efficacy were not correlated with mental toughness. In addition, mental toughness was found to be correlated with pain-coping and negatively correlated with paincatastrophizing. Finally, mental toughness was significantly related to each of the three adherence measure; however, only attendance displayed a positive association, while both clinic and home based rehabilitation revealed a negative relationship. Comments The aim of this study was to adopt the 4Cs approach toward mental toughness 11 in establishing whether this construct impacts upon beliefs, pain, and adherence within a sport injury rehabilitation context. Findings revealed no association between mental toughness and coping appraisals; however, results did indicate that more mentally tough individuals perceived their injury to be less threatening (severe) and less susceptible to further injury than their lower mentally tough counterparts. This finding was emulated with regard to pain in that more mentally tough individuals were better able to cope

252 Levy with pain during rehabilitation. In contrast, low mentally tough individuals were found to dwell upon the pain during rehabilitation and potentially despair when the pain is unbearable. A final factor relating to pain, somatic awareness, which relates to whether a person is hyposensitive or hypersensitive to painful stimuli, was not found to be influenced by the degree of mental toughness. With regard to rehabilitation adherence, greater attendance at rehabilitation sessions was displayed by those who had higher levels of mental toughness. However, findings from the SIRAS indicated that lower mentally tough individuals displayed more constructive behaviors during clinic rehabilitation. Bivariate correlations replicated this finding with regard to home based adherence; however, follow up analysis of variance indicated no significant difference between high/medium/low mentally tough individuals. Recent findings relating to mental toughness in sport deems the ability to withstand physical pain to be an important attribute of mentally tough individuals. 10 Further to this, Crust and Clough 20 found mental toughness to be related with physical endurance, citing participantsʼ ability to block out the pain to be a possible contributing factor. These findings complement the results of the present study, which indicate that more mentally tough individuals use direct coping strategies that enable them to ignore pain. Thereby, in order to facilitate rehabilitation, it may be beneficial to improve the mental toughness of those individuals who are unable to cope with pain during rehabilitation; however, more research is required in targeting specific pain coping strategies that ameliorate mental toughness. Previous research that considers threat appraisals in the health domain suggests hardy individuals make less threatening appraisals of stressors. 12 This finding aligns with the results from the present study, which suggest that high mentally tough individuals have positive perceptions of their injury compared to lesser mentally tough individuals. The importance of favorable appraisals has been recognized in the health literature, which regards hardiness (mental toughness) to protect wellness and stimulate effective functioning despite stressful circumstances; 15 however, contrary to evidence documented in health psychology, it must be acknowledged that research within the sport injury rehabilitation adherence literature suggests less favorable threat appraisals are an important motivating influence in the decision to adhere with prescribed rehabilitation modalities. 4,5 Similarly, the present results suggest low mentally tough individuals, characterized by negative appraisals, were found to adhere better to clinic based rehabilitation activity than high mentally tough individuals who hold more favorable threat appraisals. Despite the benefits of being mentally tough with respect to pain and threat appraisals, there is a possibility that this characteristic may have a negative influence upon rehabilitation adherence and recovery outcomes. This may be due to high mentally tough individuals appraising their injury to be less severe and less susceptible to reoccur and thereby perceive compliance to clinic based activity to be less important. Additionally, given that low mentally tough individuals typically display a low sense of confidence and control, 11 it is possible that physiotherapists may have provided greater support in terms of task appreciation or informational support. Previous research has found the latter to be associated with greater adherence to clinic based modalities; 21 therefore, given that high mentally tough individuals are characteristically high in confidence and control, 11 they may not have required as much support from the physiotherapists and subsequently were

Mental Toughness in Rehabilitation 253 not exposed to the benefits that low mentally tough individuals experienced. More research is required before this contention can be confirmed. Although mentally tough individuals did recognize the need to attend rehabilitation sessions, physiotherapists may need to be aware that recovery outcomes with high mental toughness groups may be inhibited due to poor performance of clinic based modalities. From an applied perspective, contrary to evidence from the health psychology literature, it may not be advantageous for low mentally tough individuals to adopt positive threat appraisals. Furthermore, physiotherapists may need to ensure adequate clinic based support for both high and low mentally tough individuals. Despite the present findings, some key limitations warrant mention. Primarily, the results are correlational in nature and thus do not indicate causation. In order to address this issue, experimental research is needed in which threat appraisals, pain, and adherence to sport injury rehabilitation are manipulated and the effects on mental toughness evaluated. Second, the relative homogeneity of the sample with respect to injury may limit the generalizability of the results. Hence, additional inquiry regarding different types of injury is necessary. Finally, to enhance the accuracy of home-based rehabilitation adherence data, objective measures such as electronic monitors should be favored above self report measures. In conclusion, the present study suggested mental toughness to be related with beliefs, pain, and adherence within a sport injury rehabilitation context. Initial studies investigating mental toughness within a sporting context have highlighted the benefits of being mentally tough; however, before physiotherapists and sport psychologists apply interventions to improve mental toughness in dealing with injured athletes, they may need to be aware of the consequences of being mentally tough and its effects upon rehabilitation behavior. References 1. Department of Health, Physical Activity, Health Improvement and Prevention. At least fi ve a week: Evidence on the impact of physical activity and its relationship to health. London: Department of Health; 2004. 2. Petridou E, Belechri M, Dessypris N, et al. Sports Injuries in the EU Countries in View of the 2004 Olympics: Harvesting Information From Existing Data Bases. Athens: Centre for Research and Prevention of Injuries among the Young; 2003. 3. Daly JM, Brewer BW, Van Raalte JL. Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. J Sport Rehabil. 1995;4:23-30. 4. Taylor AH, May S. Threat and coping appraisal as determinants of compliance with sports injury rehabilitation: an application of protection motivation theory. J Sport Sci. 1996;14:471-482. 5. Brewer BW, Cornelius AE, Van Raalte JL, et al. Protection motivation theory and adherence to sport injury rehabilitation revisited. The Sport Psychol. 2003;17:95-103. 6. Byerly PN, Worrell T, Gahimer J, et al. Rehabilitation compliance in an athletic training environment. J Athl Training. 1994;29:352-355. 7. Fields J, Murphey M, Horodyski, M, et al. Factors associated with adherence to sport injury rehabilitation in college-age athletes. J Sport Rehabil. 1995;4:172-180. 8. Fisher AC, Domm MA, Wuest DA. Adherence to sport injury rehabilitation programs. Physician Sportsmed. 1988;16:47-50.

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