Literature Review

Views of chartered physiotherapists on the psychological content of their practice: a preliminary study in the United Kingdom

B Hemmings and L Povey (2002) from the Division of Sport Sciences at the University of Northampton undertook mixed method research to investigate the perceptions of chartered physiotherapists on the psychological content of their practice and to determine what could be done to support these two processes going forward.

This research is considered so important because “although research into the psychological aspects of sports injury is increasing and psychological interventions have been identified as important in the rehabilitation process, few studies have focused on how sports medicine practitioners deal with psychological problems.”  Advancements in the understanding of the impact of psychology on sports injuries has put this at the forefront of many physiotherapists’ minds and “helping athletes cope with the psychological stresses and demands that injury places on them has been identified as an extremely important role for injury rehabilitation personnel.”

With clear documented evidence that these two practices should run concurrently changes can potentially be made to the work conducted by physiotherapists in this area and in the training of future physiotherapists. As my research looks particularly at the impact physiotherapy might have on the psychology of dancers the two studies are closely aligned and so may support each other in this complex research area.

Hemmings and Povey sent questionnaires to all 179 chartered physiotherapists in their region and received 90 (50%) responses. The respondents were of mixed gender with a mean age of 40 and an average of just over nine years’ experience in their field. They treated both recreational and professional sporting injuries and treated an average of 15.3 injuries per month. Only two of the 90 surveyed had a postgraduate qualification in psychology.

The aim of the questionnaire was to “measure perspectives” with regard to the psychological content of the physiotherapists’ work. There were eight questions in total covering statistical, quantitative data such as likert scales and closed questions to qualitative open-ended questions asking physiotherapists to identify behaviours and characteristics most commonly associated with successful or non-successful physiotherapy outcomes.

“Descriptive statistical and qualitative analysis showed that physiotherapists believed athletes were often psychologically affected by injury” with stress, anxiety, depression and exercise addiction cited as the most commonly encountered conditions. The result analysis of the questionnaires then went on to look at the characteristics of athletes who do cope successfully with sports injuries. Compliance with the rehabilitation programme and a positive attitude to life and injury came out on top, with motivation, determination and patience next on the list of important factors. So what about the characteristics of those athletes who don’t cope as well with treatment? Non-compliance with treatment, impatience and lack of motivation all scored highly showing that following the rehabilitation and treatment offered closely would appear to have the greatest impact on the psychology of the injured party, something which I will monitor closely in my own study.

The next questions asked physiotherapists what techniques they used when dealing with the psychology of their patients and what they considered important for physiotherapists to learn moving forward.  Creating variety in rehabilitation exercises, setting short term goals and encouraging positive self-talk were used most often (over 75% of the time) and these skills also made it into the top five techniques the surveyed physiotherapists felt were important for those training in their field to learn. However, understanding individual motivation and reducing stress and anxiety also appeared in this top five and yet weren’t cited as techniques commonly used in the previous table.

Interestingly, despite the clear understanding that psychological processes are important in the treatment of sports injuries only 8 of the 90 physiotherapists surveyed had ever referred an athlete for counselling and although they were able to observe and identify particular strategies that would be helpful to recovery all expressed a desire to learn more about psychological techniques in order to enhance and improve their work.

This study provides a strong indication of what physiotherapists feel will be of benefit to them in the future and highlights the need for a sound education in the theory and practice of psychology in the training of sports physiotherapists. Of course, Hemmings and Povey realise that in order to strengthen their study a larger sample from across the United Kingdom needs to be undertaken but there is an increased understanding in this previously neglected area of study with research by the likes of Ahern and Lohr (1997) and Wagman and Khelifa (1996) looking further into the pychosocial and psychological issues faced in sports injury rehabilitation.

Psychological Correlates of Dance Injuries

In 1993 Lynda Mainwaring, Gretchen Kerr and Donna Krasnow saw a sizeable gap in research in the area of dance injuries and so in this study,’ Psychological Correlates of Dance Injuries’, aimed to investigate stress and self-esteem in particular as possible psychological correlates with injured dancers.

In a previous study Kerr, Krasnow and Mainwaring (1994) discovered that the injury rate in dance is reportedly as high as 97% over an eight month period and yet, despite this high incidence, there is relatively little research into the area showing that my study could add valuable evidence to a relatively untapped area.

My research will look particularly at the impact physiotherapy can have on the psychological recovery process while here Mainwaring, Kerr and Krasnow explore whether or not stress factors and low self-esteem give rise to more prevalent injuries.

The research was conducted using a mixed method approach with similar tools of enquiry to my own, however,  the sample size was bigger. Thirty nine female dance students were selected to take part in the study with a mean age of 21. The dancers studied both ballet and modern dance but were primarily being trained in the latter. The dancers were given four assessments over an eight month period involving two stress level surveys (a Life Experiences Survey – LES, and a Dance Experiences Survey – DES) which used a scale of -3 to +3 as to the effect of certain events in their lives. The second survey looked more particularly at the impact of unique stressors to dance, for example: performances, castings, exams and maintaining ideal body weight.

For measuring self-esteem the Rosenberg Self-Esteem Scale was issued where respondents were invited to answer ten questions using a 4 point Likert scale ranging from strongly disagree to strongly agree. In addition a semi-structured interview was conducted at each stage based around the responses to each survey.

The researchers were conscious to first define injury and for the purposes of their study it was defined as “physical harm resulting in pain or discomfort which causes one, or more than one, of the following:  stopping activity, negative effects on training or performance or sufficient distraction to interfere with concentration.” Dancers also kept injury logs where they identified the day they were injured and the duration of the injury.

The results found that there is a strong correlation between psychological stress and injury particularly with regards to the duration of the injury. As negative stress increased so too did the duration of the injury and vice versa, leaving dancers in a vicious cycle. There was no difference between the life experience stress or the dance experience stress.

The study was also the first to look at the relationships between self-esteem and injured in dance but the research found no significant correlations in this area.

Despite this the study emphasises the need to consider psychological aspects of the injury process. The authors recommend that dancers, teachers and medical practitioners enhance their awareness of negative psychology in treatment to prevent or reduce injuries which is something I hope my study supports.

Significant results had already shown links between stress and injury in a number of other sports and so it is no real surprise that there are correlations in dance too. However, it is widely recognised that dance is an area, although containing significant similarities with sports, is under researched, and the authors hope that further attention is devoted to the psychology of the dancer. Studies by Sohl and Bowling (1990) and Solomon (1990) go some way to addressing this.



Ahern, D.K. and Lohr, B.A., 1997. Psychosocial factors in sports injury rehabilitation. Clinics in sports medicine16(4), pp.755-768.

Hemmings, B. and Povey, L., 2002. Views of chartered physiotherapists on the psychological content of their practice: a preliminary study in the United Kingdom. British journal of sports medicine36(1), pp.61-64.

Krasnow, D., Kerr, G. and Mainwaring, L., 1994. Psychology of dealing with the injured dancer. Med Probl Perform Art9(1), pp.7-9.

Mainwaring, L., Kerr, G. and Krasnow, D., 1993. Psychological correlates of dance injuries. Medical Problems of Performing Artists8, pp.3-3.

Sohl, P. and Bowling, A., 1990. Injuries to dancers. Sports Medicine9(5), pp.317-322.

Solomon, R., 1990. Preventing dance injuries: An interdisciplinary perspective. AAHPERD Publication Sales Office, 1900 Association Drive, Reston, VA 22091..

Wagman, D. and Khelifa, M., 1996. Psychological issues in sport injury rehabilitation: current knowledge and practice. Journal of Athletic Training31(3), p.257.