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West Virginia University Lindsey Leatherman West Virginia University Follow this and additional works at: https://researchrepository.wvu.edu/etd Part of the Psychology Commons, and the Sports Sciences Commons Recommended Citation Leatherman, Lindsey, "Multidisciplinary approach to injury rehabilitation: The D1 college athlete perspective" (2024). Graduate Theses, Dissertations, and Problem Reports. 12582. https://researchrepository.wvu.edu/etd/12582 This Thesis is protected by copyright and/or related rights. It has been brought to you by the The Research Repository @ WVU with permission from the rights-holder(s). You are free to use this Thesis in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you must obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/ or on the work itself. This Thesis has been accepted for inclusion in WVU Graduate Theses, Dissertations, and Problem Reports collection by an authorized administrator of The Research Repository @ WVU. For more information, please contact researchrepository@mail.wvu.edu. Multidisciplinary approach to injury rehabilitation: The D1 college athlete perspective Lindsey Leatherman, B.S., B.A. Thesis submitted to the College of Applied Human Sciences at West Virginia University School of Sport Sciences in partial fulfillment of the requirements for the degree of Master of Science in Sport, Exercise, and Performance Psychology Samuel Zizzi, Ed.D., Chair Ashley Coker-Cranney, Ph.D. Julie Partridge, Ph.D. School of Sport Sciences Morgantown, West Virginia 2024 Keywords: Injury, multidisciplinary model of care, collegiate student-athletes, social support Copyright: 2024 Lindsey Leatherman ABSTRACT Multidisciplinary approach to injury rehabilitation: The D1 college athlete perspective Lindsey Leatherman, B.S., B.A. Sport injuries continue to be unavoidable disruptions in student-athletes’ athletic careers with over 200,000 injuries estimated to be reported each year in college sport (Kerr et al., 2015). Researchers continue to emphasize the importance of an interprofessional approach to rehabilitation to help athletes manage the adverse psychological and emotional reactions to injury (Appaneal et al., 2009; Gervis et al., 2020; Putukian, 2016). The purpose of this study was to extend and replicate the research of Clement and Arvinen-Barrow (2021) by incorporating perspectives of Division I US student-athletes. The current study describes 321 NCAA Division I collegiate athletes’ experiences of receiving interprofessional care during injury rehabilitation. A secondary purpose of the study was to explore perceptions of, and access to, sport psychology professionals during rehabilitation. Participants were asked to complete a multidisciplinary team categorization tool (e.g., primary vs. secondary), a modified version of the Social Support Survey (Corbillon et al., 2008), open-ended questions, injury details, and demographic variables. After several rounds of email and in-person recruitment lasting approximately three months, 321 Division I student-athletes across 16 NCAA conferences participated in the cross-sectional study. Athletes placed athletic trainers, athletic coaches, and strength and conditioning coaches most commonly on the primary rehabilitation team. Additionally, athletic coaches, strength and conditioning coaches, and physicians were most frequently identified as secondary rehabilitation team members. Overall, mental health supports were the most missed services identified by participants. For those that did work with one of these professionals, the main themes that emerged were helpfulness of a safe space and feeling supported beyond sport. This study provided support for the use of the multidisciplinary model of sport injury rehabilitation within the context of collegiate athletics. College Athlete Perspective iii Table of Contents Multidisciplinary approach to injury rehabilitation: The D1 college athlete perspective..... 1 Methods.......................................................................................................................................... 5 Design ......................................................................................................................................... 5 Participants.................................................................................................................................. 5 Procedure .................................................................................................................................... 6 Measures..................................................................................................................................... 7 Demographics..................................................................................................................... 7 Multidisciplinary Team Categorization .............................................................................. 7 Modified Social Support Survey......................................................................................... 8 Open-ended questions......................................................................................................... 8 Data analysis............................................................................................................................... 9 Results.......................................................................................................................................... 10 Demographics........................................................................................................................... 10 Primary and Secondary Team Categorizations......................................................................... 11 Perceptions of Social Support During Rehabilitation............................................................... 12 Effect of Sport Type and Rehabilitation Length on Social Support Perceptions ..................... 13 Sport Type Categorizations............................................................................................... 13 Length of Rehabilitation ................................................................................................... 13 Qualitative Analyses of Open-Ended Responses...................................................................... 14 Rehabilitation Team Members’ Categorizations.............................................................. 14 Identification of Missing Professionals ............................................................................ 15 Experiences Working with Either an SPC or LMHP........................................................ 15 Discussion .................................................................................................................................... 16 Limitations................................................................................................................................ 22 Conclusions............................................................................................................................... 23 References.................................................................................................................................... 25 Tables........................................................................................................................................... 32 Table 1 ...................................................................................................................................... 33 Demographic Information on the Participants Who Provided Their Information................... 33 Table 2 ...................................................................................................................................... 34 Injury Descriptives of Participants........................................................................................... 34 Table 3 ...................................................................................................................................... 35 Identified Members of Injury Rehabilitation Process and Perceptions of Support.................. 35 Table 4 ...................................................................................................................................... 36 College Athlete Perspective iv Means, Standard Deviations, and Results of Mixed Analyses of Variance Regarding Variables Influencing Social Support Scores............................................................................................ 36 Figures.......................................................................................................................................... 37 Figure 1 ..................................................................................................................................... 38 Frequencies of professionals/individuals identified as either the primary or secondary sport injury rehabilitation team. ........................................................................................................ 38 Figure 2 ..................................................................................................................................... 39 Social Support Means and Sport Type...................................................................................... 39 Figure 3 ..................................................................................................................................... 40 Social Support Means and Rehabilitation Length: Currently Completing Rehabilitation....... 40 Figure 4 ..................................................................................................................................... 41 Social Support Means and Rehabilitation Length: Previous Completion of Rehabilitation.... 41 Figure 5 ..................................................................................................................................... 42 Frequencies of different categories of professionals/individuals distributed between the primary and secondary sport injury rehabilitation teams........................................................ 42 Figure 6 ..................................................................................................................................... 43 Structure of multidisciplinary team to rehabilitation: primary and secondary teams ............. 43 43 Appendix A: Extended Literature Review ............................................................................... 44 Introduction............................................................................................................................... 44 Psychological Factors Influencing Sport Injury ....................................................................... 45 Psychosocial Responses of Injury Rehabilitation............................................................. 45 Psychological/Emotional Responses to Sport Injury............................................ 49 Professionals Involved in Injury Rehabilitation ....................................................................... 52 Athletic Trainer................................................................................................................. 52 Education .............................................................................................................. 52 Current Usage and Understanding of Sport Psychology Interventions ............... 55 Perceptions of Interprofessional Practice Model to Injury Rehabilitation .......... 57 Sport Psychology Consultant............................................................................................ 60 Education and Competencies................................................................................ 60 Perceptions Toward Interprofessional Approach to Injury Rehabilitation.......... 61 Athlete............................................................................................................................... 62 Perceptions and Responses of Psychological Interventions During Injury.......... 62 College Athlete Perspective v Attitudes and Perceptions Towards Multidisciplinary Approach......................... 65 Proposed Professional Practice Models for Injury Rehabilitation............................................ 66 Summary................................................................................................................................... 69 References.................................................................................................................................... 72 College Athlete Perspective 1 Multidisciplinary approach to injury rehabilitation: The D1 college athlete perspective Sport comprises a large part of society and remains popular with people of all age levels. The National Federation of State High School Association reported over 7.5 million youth participating in high school athletics during the 2021-2022 academic year, and in continuation, 528,627 athletes were reported to be participating across all divisions within the National Collegiate Athletic Association (NCAA: 2021). Considering the high number of athletes involved in sports, it is expected that many will encounter injuries during their careers. Injuries continue to be an unavoidable reality encompassing complex components that athletes must overcome during the recovery process. Along with the physical detriments, emotional consequences of injuries can emerge in many different forms such as frustration, anxiety, and depression (Appaneal et al., 2009; Putukian, 2016). Numerous factors can impact the way an athlete perceives an injury and how that individual approaches the rehabilitation process. The Integrated Model of Response to Sport Injury (Wiese-Bjornstal et al., 1998) provides a comprehensive framework for understanding the sport injury experience, identifying involvement of both personal factors (e.g., athletic identity, self-motivation, and motivational orientation) and situational factors (e.g., social support, rehabilitation environment, and sport culture) that influence athlete cognitions, emotions, and behaviors, in turn affecting treatment outcomes. Previous researchers have identified that an injured athlete’s personal and situational factors are likely to affect risk behaviors (e.g. overadherence and inclination to prematurely return to sport) and beliefs following injury (Podlog et al., 2013). The most frequently reported emotional responses to more severe athletic injuries, that require at least 8 weeks out of sport, are depression and anxiety (Gervis et al., 2020). With the wide array of both physiological and emotional factors that can present during an athlete’s injury recovery process, and their ultimate College Athlete Perspective 2 impact on treatment outcomes, it is imperative to understand the comprehensive impact of these injuries on athletes’ overall well-being. In rehabilitation, a diverse team of professionals may be involved to address the various physical and psychological aspects of the injury recovery process. Within college athletics, certified athletic trainers (ATCs) are recognized by both themselves and other professionals as the directors of an athlete’s injury rehabilitation process (Arvinen-Barrow & Clement, 2015; Kraemer et al., 2019). Along with providing essential social support to the athlete for a successful recovery and return to sport (Bianco, 2001; Clement et al., 2015), ATCs also refer to and collaborate with other professionals as needed. While athletic trainers are well-educated and highly trained in addressing the physical aspects of injuries, they often receive limited training regarding the emotional ramifications of injury (CAATE, 2020). Nonetheless, many ATCs recognize the importance of providing psychological support to injured athletes (Clement et al., 2013; Cormier & Zizzi, 2015). In a study by Cormier and Zizzi (2015) assessing ATCs’ abilities to identify psychological concerns and make appropriate referral decisions, 43% of the 326 respondents believed it was their responsibility to implement psychosocial interventions during injury rehabilitation, despite other research indicating a lack of training and confidence in this domain (Arvinen-Barrow et al., 2010; Zakrajsek et al., 2017). Furthermore, Cormier and Zizzi (2015) found that while ATCs showcased a strong ability to recognize psychological concerns, many struggled to match suitable interventions with varying levels of distress. Thus, when an injured athlete presents with potential mental health concerns, it may be appropriate for an ATC to refer or consult with other professionals, such as sport psychology professionals or licensed mental health providers (LMHP), who are better equipped to provide psychosocial interventions. These mental College Athlete Perspective 3 performance or mental health professionals can assist throughout the injury rehabilitation process by addressing important components of psychological readiness regarding athletes returning to sport such as focus, confidence, and realistic expectations (Donald et al., 2024). Interprofessional collaboration, defined as a “mutually beneficial and well-defined relationship entered into by two or more [professionals] to achieve common goals” (Mattessich & Monsey, 1992, p. 7), is essential within college sport injury rehabilitation. For instance, an ATC may collaborate with a physician, sport psychology consultant, registered dietitian, certified strength coach, or any other necessary professional to facilitate comprehensive care for the injured athlete. Research indicates that ATCs recognize the importance of interprofessional collaboration in the successful rehabilitation of injured athletes (Arvinen-Barrow & Clement, 2017). Additionally, Zakrajsek and colleagues (2016) documented many ATCs already engaging in interprofessional practice within the collegiate setting. Further research has examined the perspectives of sport psychology consultants (SPCs), other professionals involved in interprofessional practice within injury rehabilitation. ArvinenBarrow and Clement (2017) explored the experiences and views of 62 SPCs regarding interprofessional care teams based on the proposed multidisciplinary team approach to sport injury rehabilitation (Clement & Arvinen-Barrow, 2013) through an online survey. The study revealed substantial support for the importance of injured athletes’ access to an interprofessional care team during injury rehabilitation, with approximately 95% of SPCs endorsing each individual listed in the conceptual multidisciplinary care team model (Clement & ArvinenBarrow, 2013) as being integral to the interprofessional rehabilitation approach (Arvinen-Barrow & Clement, 2017). College Athlete Perspective 4 Despite being central to the injury rehabilitation process, there are fewer documented cases attempting to capture athletes’ perspectives within interprofessional practice. Clement and Arvinen-Barrow (2021) retrospectively explored the experiences of 182 former high school athletes regarding their involvement in interprofessional care during injury rehabilitation. Participants were asked to complete both a blank multidisciplinary team diagram and draw a sociogram, visually depicting the communication patterns among care team members during their rehabilitation. Notably, athletes more frequently included coaches and family as part of the primary care team than the secondary team, which differed from the proposed model. However, no research has examined multidisciplinary teams through the lens of college-level athletes. Recently, the NCAA has mandated Division I schools to provide mental health services to athletes, either directly through their athletic departments or through campus services (Brutlag Hosick, 2019). However, the extent to which these services have been integrated and utilized within the injury context has not been explored. While the current literature on interprofessional approaches to injury rehabilitation demonstrates the perspective of high school athletes, athletic trainers, sport psychology consultants, and team dynamics, the viewpoints of collegiate athletes are notably absent. The purpose of this study was to replicate elements of Clement and Arvinen-Barrow’s (2021) research within the collegiate athlete population while simultaneously expanding knowledge surrounding current athlete experiences within a multidisciplinary approach to injury rehabilitation. Therefore, the research questions were: 1a) Who do college athletes interact with during their injury rehabilitation? 1b) Do injured collegiate athletes’ experiences align with the multidisciplinary sport injury rehabilitation team model? 2a) How satisfied are injured athletes with support received during rehabilitation? 2b) Does sport type or rehabilitation length College Athlete Perspective 5 influence support perceptions? 3a) Who did athletes wish to interact with during rehabilitation but did not, and why? 3b) What are injured collegiate athletes’ experiences with sport psychology consultants or licensed mental health professionals during rehabilitation? Methods This section outlines the methodological approach including research design, participant selection, data collection procedures, and data analysis methods. The objective was to explore the experiences and perspectives of collegiate student-athletes regarding their interprofessional rehabilitation teams, using a comprehensive approach to gather both qualitative and quantitative data. Design A multimethod cross-sectional survey design was used to collect descriptive data exploring college athletes’ experiences of the injury rehabilitation process. This approach was grounded in Clement and Arvinen-Barrow’s framework, facilitating comparison with the multidisciplinary model of care for sport injuries and across the variables of sport type and rehabilitation length. Descriptive research is used to identify the how, when, and where of a particular situation by attempting to identify characteristics, frequencies, trends, and/or categories to provide surrounding context (Baumgartner et al., 2021). Participants Participants were purposively recruited from NCAA Division I collegiate institutions across the United States. The inclusion criteria for schools selected included (1) the institution was an NCAA DI school and (2) a secondary team member was available to injured athletes from at least one professional (e.g. sport psychology consultant and/or licensed mental health provider). The researcher determined if institutions met the inclusion criteria by accessing College Athlete Perspective 6 athletic department websites or upon correspondence with a professional employed within the athletic department at targeted schools. The second level of sampling occurred for Division I student-athletes currently enrolled at the recruited NCAA DI institutions. To be included in the study, participants had to 1) be current student-athletes, 2) be either currently completing injury rehabilitation at their current institution or have previously completed injury rehabilitation during their time at their current institution and 3) the reported injury required time out of sport as prescribed by either a certified athletic trainer or medical doctor. Procedure Following Institutional Review Board approval in the Fall of 2023, the researcher recruited participants by visiting undergraduate classes at one institution. Upon arrival to the classroom, the researcher introduced the study (i.e., purpose, potential benefits, time commitments) and provided a QR code for interested participants to scan, directing them to the Qualtrics survey. During the same period, the researcher sent recruitment emails to employees (e.g. athletic directors, coaches, sport psychology consultants) within the athletic departments of institutions that met the inclusion criteria to request the participation of student-athletes at those institutions. The researcher informed these contacts of the study information including the purpose, potential benefits, and time commitments, and included a link for the Qualtrics survey. These methods persisted for over one month. The third method of recruitment began when the researcher collected and emailed student-athletes, individually. The researcher again, through a recruitment script, provided potential participants with the study information, potential benefits, time commitments, and a link to the online Qualtrics survey. Data collection occurred for a total of three months. Through these recruitment methods, 12,606 emails were sent to individual student-athletes and 424 college students were present for in-person recruitment. Out of the College Athlete Perspective 7 13,030 total potential participants contacted, 742 responses were received resulting in a response rate of 5.7%. This percentage is a slight underestimate due to the limitations in calculating inperson and email response rates independently. Of the responses received, 321 respondents met inclusion criteria for the present study. Each participant was contacted only once. Measures Demographics Participants were asked to report age, gender, sport type, school conference, injury type, rehabilitation length, current rehabilitation status (i.e. currently or not currently completing), and previous injury experience. Multidisciplinary Team Categorization The titles of all professionals/individuals who may have participated as part of the rehabilitation team, according to Clement and Arvinen-Barrow (2013), were listed in random order for the athlete to choose from and categorize into either primary or secondary care teams. The definitions of the terms primary care team and secondary care team were provided for participants. Primary care team members were defined as “[professionals and/or individuals] who work closely with the injured athlete from injury occurrence through the entire rehabilitation process until their successful return to [sport]”. The secondary care team was defined as “[professionals and/or individuals] who have varying degrees of interaction throughout the [athlete’s] injury rehabilitation”. Athletes were instructed to first select professionals/individuals from the randomized list and then asked to categorize only those selections. College Athlete Perspective 8 Modified Social Support Survey Participants were then asked to complete a modified version of the Social Support Survey (SSS; Corbillon et al., 2008). This modified SSS consisted of three items designed to assess perceived satisfaction with social support using a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied). The items asked, “In general, how satisfied were you with the quality of support you received during your rehab?” First, participants rated their perceived satisfaction with support from each individual or professional they specified as part of their injury rehabilitation team from the multidisciplinary team categorization instrument. Next, they rated their satisfaction with the overall quality of support received during their rehabilitation. Finally, participants rated their satisfaction with support from their reported primary rehabilitation team and their reported secondary rehabilitation team. Open-ended questions Finally, participants were invited to answer four open-ended questions, including: (1) “Describe why you rated the level of support provided by your primary rehabilitation team the way you did. Feel free to comment on individuals in your primary rehabilitation team that were more or less helpful/supportive in your recovery,” (2) “Describe why you rated the level of support provided by your secondary rehabilitation team the way you did. Feel free to comment on individuals in your secondary rehabilitation team that were more or less helpful/supportive in your recovery,” (3) “Which services would you have liked to receive during your rehabilitation that you did not get? For each service you missed, please describe how you believe the inclusion of that service would have helped your injury rehabilitation,” and (4) for those who included a CMPC or LMHP in their multidisciplinary team, “You indicated a sport psychology consultant College Athlete Perspective 9 or licensed mental health professional as part of your injury rehabilitation team, please describe your experience with this professional including what was helpful and/or unhelpful.” Pilot Study Before recruiting participants, the researcher conducted pilot testing of the survey materials. Cognitive interviews were conducted with four current NCAA Division I studentathletes who met the study’s inclusion criteria and two former DI student-athletes who retrospectively met inclusion criteria. Pilot study participants were directed to complete the survey and encouraged to provide commentary on their thoughts. There were minor adjustments made to the survey based on the responses from the six cognitive interviews. Data analysis The researcher conducted the quantitative data analysis for this study using SPSS to address several research questions. Descriptive statistics were calculated for demographic variables. Frequencies of interactions with various professionals or individuals were calculated and visually represented in a diagram to compare with the published multidisciplinary sport injury rehabilitation model (Clement & Arvinen-Barrow, 2013). This descriptive comparison allowed for the identification of similarities and differences in the interactions reported by collegiate athletes as compared to professionals during their rehabilitation process. Dependent t-tests were conducted to assess perceptions of satisfaction with the social support received from the various professionals and individuals identified, using mean scores. This analysis facilitated comparisons of support satisfaction across different levels of the rehabilitation team and among individual professionals. Additionally, the researchers performed 2x2 mixed-ANOVAs to examine the impact of sport type and rehabilitation length on social support perceptions. Initial analyses confirmed the College Athlete Perspective 10 normality of the data and verified that all theoretical assumptions were met. Interaction graphs illustrated the effects of the independent (i.e., sport type, rehabilitation length) variables on the dependent variable (i.e., social support). The independent variable “sport type” (individual vs. team sport athletes) was chosen to explore potential differences in social support, considering team sport athletes may have access to larger support networks and are accustomed to working within a team dynamic towards collective goals. The independent variable “rehabilitation length” was chosen to explore if the amount of time spent in rehabilitation influenced perspectives of social support, hypothesizing that extended rehabilitation lengths may increase interactions with a broader range of rehabilitation team members. Utilizing thematic analysis (Braun & Clarke, 2012), the researcher identified and interpreted significant patterns of data within participants’ open-ended responses. Specifically, thematic analysis permitted a nuanced understanding of collegiate athletes’ injury rehabilitation experiences and their interactions with sport psychology and mental health professionals via theme identification. Furthermore, the researcher integrated the identified themes with the quantitative findings to enrich the explanation of the data. Results Demographics Participants included 321 collegiate student-athletes representing 21 different NCAA Division I sports and 16 different conferences; 104 participants did not provide demographic information (e.g., sport, college conferences, gender, race). Given that approximately one-third of the participants did not complete the demographic questionnaire, there may be additional sports and conferences represented that were not fully documented in the analysis. The average age of participants completing the web-based questionnaire was 20.3 years old (SD = 1.4). Of College Athlete Perspective 11 these participants, 69% (n = 149) self-identified as female, 29.6% (n = 64) as male, 0.9% (n = 2) preferred not to disclose their gender, and 0.5% (n = 1) identified as non-binary/third gender. Most of the sample identified as White or Caucasian (81.5%, n = 176). For a detailed breakdown of demographics, see Table 1. Regarding rehabilitation status, 55.6% (n = 178) of participants were currently completing injury rehabilitation protocols at the time of data collection, whereas 44.4% (n = 142) reported previous completion of injury rehabilitation protocols. Using the Orchard Sport Injury and Illness Classification System (OSIICS; Rae & Orchard, 2007), respondents most commonly reported injuries to the lower limbs (e.g., knee, thigh, ankle; 54.7%; n = 173). In terms of injury severity, 72.6% (n = 233) reported severe injuries requiring over 4 weeks of rehabilitation, with the minority (27.4%; n = 88) reporting injuries requiring less than 4 weeks of rehabilitation. For detailed percentages of other injury locations and severities, see Table 2. Primary and Secondary Team Categorizations Among the primary care team, the most frequently identified members included athletic trainers (n = 264), athletic coaches (n = 106), strength and conditioning coaches (n = 92), and physicians/orthopedic surgeons (n = 92). For the secondary rehabilitation team, the most frequently identified members were athletic coaches (n = 112), strength and conditioning coaches (n = 105), and teammates (n = 104). For the visual representation corresponding to this data, consult Figure 1. Athletic coaches (n = 106) were the second most frequently reported professionals on the primary care team, but a higher percentage of participants (51.4%; n = 112) associated this profession with the secondary rehabilitation team. Similarly, strength and conditioning coaches College Athlete Perspective 12 were the third most identified members of the primary rehabilitation team (n = 92) but were more frequently placed on the secondary care team (n = 105). Mental health and mental performance professionals (i.e. psychiatrists, sport psychologists, clinical/counseling psychologists, sport psychology consultants, licensed mental health providers) were identified a total of 139 times as primary or secondary caregivers. Specifically, 20% of participants (n = 82) reported that a sport psychologist was involved in their injury rehabilitation process. Additionally, 8.8% of participants noted the involvement of licensed mental health providers, 6.6% identified sport psychology consultants, 5.6% identified clinical/counseling psychologists, and 2.5% identified psychiatrists as part of their rehabilitation team. Mental health and performance professionals were most frequently categorized as part of the secondary care team. Perceptions of Social Support During Rehabilitation Analysis of individuals involved in the injury recovery process revealed differences regarding frequency of identification and perceived support levels (see Table 3). A total of 320 participants initially indicated involvement of at least one professional provided on the randomized list. The most frequently identified professionals were athletic trainers, who received an average social support rating of 4.1 (SD = 1.2, n = 312). They were followed by athletic coaches (M = 3.7, SD = 1.2, n = 240), strength and conditioning coaches (M = 4.3, SD = 0.96, n = 214), and family/parents (M = 4.7, SD = 0.6, n = 173). Specifically pointing out mental health and mental performance professionals, based on rankings of ratings, licensed mental health providers received an average rating of 4.3 (SD = 1.10, n = 28), followed by clinical/counseling psychologists (M = 4.2, SD = 1.30, n = 18), sport College Athlete Perspective 13 psychologists (M = 4.1, SD = 0.92, n = 64), sport psychology consultants (M = 4.1, SD = 1.10, n = 21), and psychiatrists (M = 4.1, SD = 1.20, n = 8). Effect of Sport Type and Rehabilitation Length on Social Support Perceptions Sport Type Categorizations A 2x2 mixed analysis of variance was conducted to investigate differences in ratings of social support for rehabilitation care teams (primary vs. secondary) based on the classification of sport type as either team or individual sport. The results indicated no significant main effect on social support ratings for rehabilitation team levels, F(1, 204) = 0.49, p = .488. Additionally, there was a non-significant effect for the interaction of sport type on social support ratings for rehabilitation care teams, F(2, 204) = 1.16, p = .315. For a visual representation, see Figure 2. Length of Rehabilitation Researchers conducted a second set of mixed-ANOVAs to explore differences in social support ratings for rehabilitation care teams based on rehabilitation length, which were grouped into two categories to maximize group size and power for the analysis. The first category included all athletes with less than or equal to 4 weeks of rehabilitation and the second group included athletes who reported over 4 weeks of rehabilitation. These 2x2 analyses were conducted separately in the sub-group of athletes currently completing rehabilitation and those who previously completed rehabilitation. Refer to Table 4 for a visual representation of the data. Currently Rehabilitating Group. Results showed that among participants currently undergoing rehabilitation (n = 157), there was a significant main effect on social support perceptions between primary and secondary rehabilitation teams, F(1, 155) = 8.99, p = .003, η2 = .06, indicating significantly higher ratings of social support for the primary care team (M = 4.3, SD = 0.98) compared to the secondary care team (M = 3.8, SD = 1.1), with a medium effect size. College Athlete Perspective 14 However, no significant effects were found for the interaction of rehabilitation length on perceptions of social support overall, F(1, 155) = 1.33, p = .251. Although not statistically significant, participants with rehabilitation lengths equal to or less than 4 weeks tended to rate the level of social support for the secondary care team higher (M = 4.04) than those with over 4 weeks of rehabilitation (M = 3.77). Refer to Figure 3 for a visual representation. Previous Completion of Rehabilitation Group. There was another significant main effect on social support perceptions between primary and secondary rehabilitation teams, F(1, 130) = 8.90, p = .003, η2 = .06, with a medium effect size. The interaction effect between rehabilitation length and level of social support ratings was not significant F(1, 130) = 0.82, p = .368). Participants with over 4 weeks of rehabilitation (M = 4.06) rated the secondary team higher than those with equal to or less than 4 weeks of rehabilitation time (M = 3.94). Refer to Figure 4 for further insights. Qualitative Analyses of Open-Ended Responses Thematic analysis procedures set forth by Braun and Clarke (2012) were conducted to investigate themes relevant to (a) participant distinctions between primary and secondary sources of support during injury rehabilitation, (b) identification of missing professionals, and (c) experiences working with either a SPC or LMHP. The researcher reviewed all participants' openended responses to become familiar with the data before coding the data to identify recurring themes (identified below in italics). Rehabilitation Team Members’ Categorizations Two primary themes emerged as criteria for categorical differences in participant decisions regarding the placement of individuals on either the primary or secondary rehabilitation care teams: the amount of contact time and support functions. Participants College Athlete Perspective 15 expressed that individuals were frequently placed on the secondary rehabilitation team due to a lack of consistent involvement (i.e., contact time) compared to members of the primary rehabilitation team. One participant remarked, “The secondary support team, even though their support wasn’t as frequent, was always beneficial when working with them.” Secondly, participants more commonly reported receiving and seeking psychological and emotional support from the secondary team, whereas they predominantly looked to the primary team for physical support more specific to injury rehabilitation protocols. “[The secondary team] were more the emotional/mental side and they kept me motivated,” stated one participant. Conversely, about the primary team, one participant noted, “I felt that I was supported physically, but not mentally.” Identification of Missing Professionals The most frequently identified missing service was mental support. The desire for the inclusion of mental support was mentioned a total of 33 times by participants, with several individuals named as potential providers of this support, including sport psychologists, mental health counselors, and psychiatrists. One participant stated, “If I had a sports psychologist, I feel this would help me get through mental blocks, depression, and anxiety.” Other professionals that participants wished to include during rehabilitation were sport massage therapists (n = 11), either nutritionists or dieticians (n = 7), and chiropractors (n = 4). Experiences Working with Either an SPC or LMHP Of participants who identified working with either a sport psychology consultant or a licensed mental health provider, which were the two professions added to the list by the researcher, two main themes emerged regarding experiences with these professionals: a safe space and support beyond sport. Concerning a safe space, many participants described relief College Athlete Perspective 16 associated with the ability to express feelings and emotions about their injury to an individual not directly involved in their sport. One participant expressed, “It was the only place where I felt safe to break down because I was trying so hard to be strong.” Indicative of support beyond sport, participants appeared to find comfort in talking with someone who discussed topics outside sport and injury. One participant described their experience, reporting, “He talked to me like I was more than just my athletics and checked in on other areas of my life.” Despite these overarching themes, some participants indicated dissatisfaction with their experience working with these professionals. For instance, one participant stated, “I never received any coping techniques or ways to improve my mental state which was not very helpful.” Discussion According to data from over 300 collegiate student-athletes, these findings represent the first sample of student-athletes concerning their perspectives on, and perceptions of, multidisciplinary rehabilitation teams in the collegiate setting. In this sample, sport injury rehabilitation in the collegiate setting closely resembled the multidisciplinary model of sport injury rehabilitation (Clement & Arvinen-Barrow, 2013), with all professionals from the original model accounted for by at least one participant in the present study. Professionals Involved in Collegiate Injury Rehabilitation The current sample demonstrated the comprehensiveness of the individuals and professionals outlined in the multidisciplinary model (Clement & Arvinen-Barrow, 2013). Despite the original model featuring ATCs and physicians/surgeons as the only primary team members, according to ATC and SPC viewpoints (Arvinen-Barrow & Clement, 2015; 2017), student-athlete participants identified 16 additional roles they considered integral to the primary rehabilitation team. Notably, collegiate student-athletes more frequently reported athletic College Athlete Perspective 17 coaches as part of the primary rehabilitation team in comparison to the secondary team, similar to the experiences of former high school athletes (Clement & Arvinen-Barrow, 2021). This difference in athlete perceptions highlights the significant role athletic coaches play in injury rehabilitation and suggests that coaches may be well-positioned to promote interprofessional approaches to injury rehabilitation (Podlog & Dionigi, 2010). Additionally, it indicated that coaches’ roles may align closely with those of ATCs, acting as directors of injury rehabilitation processes and coordinating the involvement of other professionals (Arvinen-Barrow & Clement, 2015; Kraemer et al., 2019). Differing from previous literature, the current sample identified strength and conditioning coaches more consistently on the primary rehabilitation team, at a frequency matching that of physicians/orthopedic surgeons. This finding is not only inconsistent with the model (Clement and Arvinen-Barrow, 2013) but also contradicts the perspective of ATCs and SPCs, who considered strength and conditioning coaches as essential secondary team members (ArvinenBarrow & Clement, 2015; 2017). However, this finding can be explained by the significant roles strength and conditioning coaches typically play in collegiate athletics, particularly in developing athletes’ physical strengths (Stewart et al., 2017). Additionally, Eisner and colleagues (2014) found that both DI and DII athletes regard strength and conditioning coaches as vital to their development as athletes, with a significant positive correlation between the perceived importance of strength and conditioning and increased time spent in the weight room. Contrastingly, strength and conditioning coaches at the professional level have reported a limited role primarily toward the end of the rehabilitation process, despite recognizing the potential benefits of a more significant involvement (Armstrong et al., 2021). Barriers to earlier and increased involvement at College Athlete Perspective 18 the professional level were related to relationships and communication among other members of the rehabilitation team that may not be present at the collegiate level. Like the sample of former high school student-athletes (Clement & Arvinen-Barrow, 2021), parents and family emerged as significant support providers for injured college athletes. While parents and family were equally represented across primary and secondary rehabilitation teams, spouses and partners were more frequently identified as primary rehabilitation team members, a finding not previously documented in related literature. Additionally, sport nutritionists were predominately assigned to the primary rehabilitation team, a finding also not previously reported in the literature. This finding contradicts the original model Clement & Arvinen-Barrow, 2013), and previous perspectives of ATCs (Arvinen-Barrow & Clement, 2015), SPCs (Arvinen-Barrow & Clement, 2017), and former high school athletes (Clement & ArvinenBarrow, 2021), all who typically considered these professionals as secondary rehabilitation team members. Importantly, the incorporation of a suitable and balanced nutrition plan into athletes’ rehabilitation processes can be essential for mitigating inflammation and promoting physical healing (Papadopoulou, 2020), thus encouraging quicker recoveries (Smith-Ryan et al., 2020). Similar to the finding with strength coaches appearing on the primary team, it is possible that some Division I athletes have consistent access to nutrition professionals and consider these services central to their recovery. Compared to athletes participating at the high school level, college athletes likely have much higher access to both strength coaches and nutrition professionals. To explore potential interactions with mental performance and mental health professionals, this study expanded the list of professionals within the multidisciplinary team to include sport psychology consultants and licensed mental health providers. Approximately 15% College Athlete Perspective 19 of participants in the current study indicated the involvement of either an SPC or LMHP in their injury rehabilitation, with another 20% indicating sport psychologists, 5.6% indicating clinical or counseling psychologists, and 2.5% indicating a psychiatrist. A possible explanation for these seemingly high numbers could be attributed to the NCAA’s attempts to support student-athlete mental health, such as the release of two documents to facilitate understanding and recommended best practices (NCAA, 2014; 2016). Per the release of “Mental Health Best Practices” in 2016, the NCAA required all institutions to have mental health services available for student-athletes. Data from the current study could serve to indicate that the NCAA mandates are having a positive impact on some athletes experiencing the emotional consequences of injury. Determinants of Rehabilitation Team Categorization and Social Support Perceptions Thematic analysis revealed that participants primarily considered the consistency of interactions when categorizing team members, aligning with the model (Arvinen-Barrow & Clement, 2013). Participants also highlighted the type of support as a main determinant. Most participants expected more direct support related to the physical aspects of their injury from primary team members and rated their satisfaction with this support higher than secondary team members. This finding corresponds with previous research indicating that athletes typically seek the most support from athletic trainers during the rehabilitation phase, particularly for both informational and emotional support (Bianco, 2001; Clement et al., 2015). Participants relied more heavily on secondary team members for mental and emotional support, confirming distinct types of support received from rehabilitation team members. These novel qualitative findings can help researchers and practitioners more clearly understand athletes’ perceptions of support during rehabilitation. College Athlete Perspective 20 One explanation for higher support ratings of primary team members could be their frequent contact with participants and more instrumental role in physical healing. Previous researchers in the field of medicine found positive correlations between patient satisfaction ratings and the amount of time spent with physicians (Chung et al., 1999; Like & Zyzanski, 1987). Despite overall moderate to high perceptions of support, individual sport athletes and those undergoing rehabilitation lasting over four weeks reported lower mean ratings for social support. Whereas it may be logical to assume that participants with more severe injuries could perceive a decline in support throughout their lengthy rehabilitation, this finding contradicts previous research. Taylor and May (1995) found significantly higher levels of satisfaction among athletes experiencing more severe injuries requiring at least four weeks of rehabilitation. Conversely, the overall highest support for the primary team was reported by participants who had previously completed rehabilitation and had less severe injuries requiring less than four weeks of recovery. A potential explanation for the influence on perceptions of past support could be “rosy retrospective bias,” (Mitchell et al, 1997), where individuals tend to recall experiences more positively after they are over compared to during the experience. Additionally, it is possible that progress in rehabilitation is more tangible and measurable for the physical aspects of recovery than for the psychological components. Interestingly, the highest rating for the secondary rehabilitation team was reported by participants who had previously completed rehabilitation and had been in protocols for over four weeks. Injury severity is a contributing factor to how an athlete perceives and responds to a sport injury (Wiese-Bjornstal et al., 1998) and more severe injuries can contribute to more severe emotional responses (Gervis et al., 2020). Thus, athletes with more severe injuries facing longer rehabilitation durations may rely more heavily on the secondary rehabilitation team than athletes College Athlete Perspective 21 with less severe injuries. This assertion is supported by data from the current participants who noted the most important functions of the secondary team as mental and emotional support. A further explanation could be that those requiring longer rehabilitation periods may just have had more time to have contact with secondary rehabilitation team members. Professions Missing in Collegiate Rehabilitation Even in Division I environments, participants highlighted the absence of certain professionals and services in their injury rehabilitation. Missing services and professionals included mental support from various providers, sport massage therapists, nutritionists or dietitians, and chiropractors. Participants also expressed a desire for increased coach understanding and communication during injury recovery. Athletes commonly seek support from their coaches during injury rehabilitation (Yang et al., 2010), and the absence of this support can negatively impact their emotional responses to injury, potentially impeding the rehabilitation process (King et al., 2023). The significance of communication, as highlighted in participants’ open-ended responses, emphasizes its crucial role in effective interprofessional collaboration and athletes’ perceptions of support (Hess & Meyer, 2021). Consistent with the multidisciplinary team concept, ATCs typically serve as central communicators within the collegiate environment, coordinating between various professionals (Karol, 2014). Whereas multidisciplinary collaboration offers numerous benefits in injury rehabilitation, it also presents challenges, such as communication breakdowns, where stakeholders, including athletes, may not receive timely and adequate updates on injury and rehabilitation status. Although transdisciplinary team approaches represent the ideal for interprofessional collaboration, a more realistic shift for the collegiate injury rehabilitation environment would be towards interprofessional collaboration, first. This transition College Athlete Perspective 22 would foster greater collaboration among individuals involved in the injury rehabilitation process for treatment planning (Karol, 2014), aiming to alleviate communication stressors for injured athletes. The mention of communication is key to the importance of this study and for future research to continue to explore. This study, along with previous research (e.g., Arvinen-Barrow & Clement, 2015; 2017; Clement & Arvinen-Barrow, 2021, Hess & Meyer, 2021; Hankemeier & Manspeaker, 2018) has provided support for the multidisciplinary model of injury rehabilitation for multiple sport contexts. However, it remains crucial for further research to investigate how multidisciplinary teams can operate more effectively, with communication a pivotal factor in this regard, and how potential shifts could be made towards a more interdisciplinary approach to injury rehabilitation within the collegiate environment. Subsequent studies should explore athlete viewpoints across diverse competition levels (e.g. Division II, Division III, NAIA, etc.,) as athletic departments’ financial resources can influence the care provided and thus the injury experience. To better understand potential aspects of change that could enhance the quality of injury rehabilitation care, future research should also consider a qualitative approach. Limitations Whereas this study explored the first sample of collegiate student-athletes on their experiences with a multidisciplinary model of sport injury rehabilitation, several limitations persisted. One limitation is the low response rate of 5.7%, as only a small proportion of the targeted sample participated in the study. Low response rates can potentially lead to issues with generalizability, meaning the data may not be representative of all NCAA Division I athletes who have experienced an injury at their collegiate institution. Despite the NCAA reporting a College Athlete Perspective 23 response rate of 31% for NCAA Division I athletes in response to an emailed time demand survey when distributed by athletic directors and coaches (NCAA, 2016), the present study represents one of the largest datasets on Division I college athletes’ perceptions of social support amongst interprofessional rehabilitation team collaboration relative to injury recovery. Another limitation is the cross-sectional nature of this study as this data is only representative of studentathlete perceptions at a single time point, limiting the ability to establish causal relationships between variables. Further research should look to assess changes over time from the onset of injury through return-to-sport phases of injury recovery. There may also be recall bias present in the study for those participants who had previously completed rehabilitation, which could affect accurate depictions of recollections of their experience. Conclusions Injured collegiate student-athletes interact with many individuals throughout their rehabilitation, with ATCs remaining in a crucial “director” role. College athletes were moderately to highly satisfied with all stakeholders and overall rehabilitation teams. Additionally, the study revealed some nuances within the collegiate environment compared to previous research, which is crucial for understanding how improvements can be made to the rehabilitation process for better care of injured athletes. In general, a significant number of injured student-athletes interacted with either a mental performance or a mental health professional, indicating their access to these resources throughout the rehabilitation process. Moreover, there was a notable level of interest among those who were not currently working with these professionals, suggesting a desire for these services. 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