Abstract
Introduction
Despite the traditional focus on assessment of athletes’ physical readiness to return to sport, mounting evidence suggests that consideration of psychological readiness is critically important in ensuring that individuals safely and effectively resume competitive activities.
Objectives
The primary aims of this narrative review are to: (1) evaluate existing measures assessing psychological readiness; (2) examine various components of psychological readiness among skiers (the focus of the current special issue); (3) discuss biopsychosocial factors that facilitate and/or undermine psychological readiness; and (4) highlight implications of psychological readiness for return to sport outcomes and articulate future research directions.
Methods
A literature search was performed in Scopus, PsycInfo, and PubMed using the keywords “psychological readiness”, “ski injuries”, “snowboard injuries”, “return to sport”, and “concussions.”
Results
Existing measures of psychological readiness are limited by conceptual ambiguities and measurement shortcomings. Limited research with skiers and snowboarders suggests that cognitive, affective, and behavioral elements of psychological readiness outlined in past work is apparent among skiers. Physical (issue healing and body system recovery), psychological (personality, recovery motivation) and social (social support, trust in rehabilitation providers) factors can facilitate and/or undermine psychological readiness. Psychological readiness predicts salient post-injury outcomes, such as the likelihood of returning to sport, re-injury, as well as the quality of post-injury performances.
Conclusions
Future research is needed to further delineate the nature of psychological readiness among skiers and snowboarders. Existing evidence, however, suggests a variety of biopsychosocial factors contribute to athletes’ psychological readiness which may be a key predictor of salient post-injury outcomes.
Keywords
Introduction
Musculoskeletal (MSK) and concussive injuries are commonplace in skiing and snowboarding.
1
,2
In an assessment of 29 Canadian winter resorts, skiers experienced as many as 52,000 musculoskeletal injuries while skiing between 2008 –2018.3
Dickson and colleagues found that knee injuries represented the majority (33%) of injuries, followed by lower leg, and ankle injuries3
These findings are consistent with other large population studies that have found lower extremity injuries to represent anywhere from 45-55% of alpine ski injuries.4
, 5
, 6
A clinical review of alpine skiing injuries across various nations by Davey and colleagues7
found that knee injuries were the most common type of injury (27-41%), whereas wrist (20%),8
shoulder (12-16.8%),4
,9
, 10
, 11
and head/face (14.2-17.9%)6
,12
injuries were also commonly experienced within this population. Further, skiers and snowboarders may be susceptible to concussion, given the velocity and forces experienced by the body during falls13
Concussion is defined as a traumatic brain injury that results from biomechanical forces transmitted via a direct or indirect blow to the face, head, or elsewhere on the body.14
MSKI and concussion can present skiers and snowboarders with a range of physical and psychological challenges. These physical challenges may include pain and impairments in joint motion and stability, muscular strength and endurance, and sensorimotor function.
14
Similarly, for skiers/snowboarders with concussion, a range of deleterious pathophysiological consequences manifesting as signs and symptoms of brain disruption (headaches, nausea, balance impairment, drowsiness) may be arduous to contend with.14
,15
From a psychological standpoint, a host of negative emotions (e.g., worry, fear, stress, anxiety, sadness), motivational decrements, feelings of isolation, and loss of confidence in one's skiing and snowboarding capabilities may all be common.16
, 17
, 18
Despite the aforementioned challenges, like other athletes, many skiers and snowboarders attempt a return to sport (RTS) following injury.
16
, 17
, 18
, 19
In an effort to optimize the RTS, return to ski transition programs typically focus on developing competitive skiers’ physical competencies, such as balance, proprioception, strength, and muscular endurance.18
Recent evidence, however, indicates that assessment of physical function alone may be inadequate for comprehensively assessing competitive skiers and snowboarders’ readiness to RTS. For instance, in their meta-analytic examination of physical RTS tests after ACL surgery, Webster and Hewett20
found that only one out of 18 studies showed that passing RTS test batteries led to greater RTS rates. Counterintuitively, passing a RTS test battery increased the risk for a subsequent contralateral ACL injury (risk ratio (RR) 3.35 [95% CI 1.52-7.37]). These findings suggest that commonly employed tests (e.g., agility, strength, muscle mass/size) designed to assess athletes’ readiness to RTS and avoid re-injury may be inadequate and do not account for other putative sources that could impede RTS.Non-physical factors – namely social (environmental) and psychological factors – have been shown to profoundly impact on the quality and effectiveness of athletes’ rehabilitation and their RTS following injury – that is the time frame when athletes are transitioning from sport-specific activities to competitive play.
21
For example, an athlete's social support, their trust in rehabilitation provider's competence, and feelings of separation or isolation from one's usual training environment may have salient implications for rehabilitation outcomes.15
,21
Additionally, psychological factors including fear of re-injury, lack of confidence in performing sport-specific skills, motivational issues, and internal and external pressures to expedite the RTS can mitigate the likelihood that athletes RTS, and can increase risk of re-injury and lost training days among those who do RTS.15
,21
,22
One psychological factor that has recently garnered attention in the sports medicine literature is “psychological readiness.” Increasing evidence suggests that psychological readiness may have important implications for a variety of post-injury outcomes such as the likelihood of RTS, re-injury, and the quality of post-injury competitive performances.
23
Consistent with the focus of this special issue, our aim is to examine research on psychological readiness to RTS – with a particular emphasis on skiers and snowboarders seeking a RTS following MSKI and concussion. First, we discuss different measures used to assess psychological readiness. Given conceptual differences between the measures, we outline a unified definition of psychological readiness to guide research and clinical practice. Second, we highlight the various components of psychological readiness found in empirical studies with skiers. Third, we use a biopsychosocial model to examine factors that may facilitate and/or mitigate psychological readiness. Fourth and finally, we discuss implications of psychological readiness for RTS outcomes and articulate suggestions for further research.Psychological Readiness Measures
Several psychological readiness measures exist including the ACL-RSI,
24
the Injury-Psychological Readiness to Return to Sport,25
and the Psychological Readiness of Injured Athlete to Return to Sport (PRIA-RS) questionnaire.26
,27
Webster and colleagues24
established the 12-item multidimensional, injury-specific ACL-Return to Sport after Injury (ACL-RSI) Scale to assess athletes:’(1) emotions (“Are you nervous about playing your sport?”); (2) confidence in performance (“Are you confident that your knee will not give way by playing your sport?”); and (3) risk appraisal (“Do you think you are likely to re-injure your knee by participating in your sport?;) when returning to sport after ACL reconstructive surgery. A short, 6-item version,28
and various injury specific versions exist for use with shoulder (SI-RSI),29
hip arthroscopy (Hip-RSI)- Gerometta A
- Klouche S
- Herman S
- Lefevre N
- Bohu Y.
The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability.
Knee surgery, sports traumatology, arthroscopy. 2018; 26: 203-211
30
and ankle instability patients (ALR-RSI).31
Glazer- Sigonney F
- Lopes R
- Bouché PA
- et al.
The ankle ligament reconstruction-return to sport after injury (ALR-RSI) is a valid and reproducible scale to quantify psychological readiness before returning to sport after ankle ligament reconstruction.
Knee surgery, sports traumatology, arthroscopy. 2020; 28: 4003-4010
25
developed a 6-item unidimensional measure of psychological readiness – the Injury Psychological Readiness to Return to Sport (I-PRRS) – equating readiness solely with confidence (e.g., “My overall confidence to play is;”, My confidence to play without pain is”, and “My confidence to not concentrate on the injury is”). Finally, a third, sport-specific readiness scale, the Psychological Readiness of Injured Athlete to Return to Sport (PRIA-RS) questionnaire, was developed to assess soccer players’ psychological readiness to return to sport after injury.27
,26
The 10-item inventory purported to assess returning athletes’ “confidence, the individual perception, the insecurity and the fear of re-injury reported by the athlete at the end of the recovery process.”26
Sample items include: “How do you evaluate the progression you have experienced during the rehabilitation/sport functional recovery period since your injury?”; “How is your mood”; “What is your physical state in view of a potential return to the team?”; and “Are you feeling nervous about returning to regular training with the team?”.Multidimensional conceptualizations of psychological readiness have been supported in two qualitative studies involving interviews with athletes from the UK and Australia.
32
,33
Based on individual and focus group interviews with seven English athletes from various sports, Podlog and colleagues33
found that psychological readiness was comprised of three components including: (a) confidence in returning to sport; (b) realistic expectations of one's sporting capabilities; and (c) motivation to regain previous performance standards. Kunnen32
documented that confidence and a ‘love of the game’ were key elements of psychological readiness that enabled a RTS following ACL reconstruction among 21 Australian soccer players. Moreover, both Kunnen32
and Podlog33
reported that the confidence component of readiness was multidimensional in that it consisted of a belief in the efficacy of the rehabilitation program, confidence and trust in rehabilitation professionals, a belief that one's formerly injured body part was fully healed, and efficacy in one's performance capabilities.While the aforementioned measures and qualitative investigations further understanding of the nature of psychological readiness, a number of limitations are evident. First, the ACL-RSI has overlapping item content between two subscales – emotions (“Are you fearful of re-injuring your knee by playing your sport?” and “Are you afraid of accidentally injuring your knee by playing your sport?”) and risk appraisals (“Do you think you are likely to re-injure your knee by participating in your sport?) – purported to represent distinct constructs. As such, it is unclear if the ACL-RSI has multiple dimensions or whether there is only a single latent factor representing psychological readiness more globally. Indeed, principal component analysis from the original scale development only revealed one underlying factor with an eigenvalue of 8.14.
24
Second, although the I-PPRS is practical given it concise nature, its applicability with a wide range of sport types, and evidence highlighting its construct validity (it measures what it purports to measure – i.e., confidence to return to sport) and internal consistency, its sole focus on confidence suggests it may lack content validity. That is, research suggests there may be other dimensions of psychological readiness beyond confidence, not captured by the inventory.15
,24
,33
Third, both the ACL-RSI and the I-PRRS lack theoretical grounding and limited athlete perspectives were solicited in their development. Fourth, with respect to the PRIA-RS, many of the items lack clear meaning and evidence of validity and reliability are limited. Whether the lack of item clarity of the PRIA-RS is a function of translation issues or whether the items could be considered ambiguous in their native Spanish is unclear. Fifth, psychometric testing of the aforementioned inventories has been largely conducted with athletes 18 years and older. As such the validity and reliability of such measures with pediatric populations remains unknown. Sixth, the aforementioned measures may lack ecological validity in so far as psychological readiness is likely sport and/or task specific. For instance, an athlete with an ACL injury may be ready to run in straight lines but not necessarily to cut or pivot while skiing. Given the generic nature of extant readiness measures, they may fail to capture sport-specific requirements.Given the discrepancies and limitations associated with current readiness measures, it is worth offering a conceptually coherent, unified definition of psychological readiness based on previous empirical work, to guide further research and clinical practice. Highlighting the multidimensional nature of the construct, Podlog and colleagues
23
recently proposed the following multidimensional definition to facilitate further research on the topic: “Psychological readiness to RTS after injury reflects an individual's state of mental preparedness to resume sport-specific activities and is comprised of three dimensions, including cognitive appraisals (confidence, expectations, motivations, risk appraisals, internal or external pressures), affective (anxiety or fears about re-injury or movement, moods) and behavioral components (approach-avoidance behaviors to demonstrate physical function/neuromuscular control, and engage in sport-specific tasks).”Noticeably absent from this definition was a physical, social, or contextual component. As Podlog
23
argued, although physical, social and contextual factors (e.g., history of injuries, social support, sub-cultural norms and values, interactions with injury stakeholders, titration of return-to-sport activity at conclusion of physical rehabilitation, access to rehabilitation facilities) may impact psychological readiness, such factors are not in and of themselves, part of psychological readiness, which, the authors proposed is an intra-individual state of mind.Components of Psychological Readiness Found in Skiers
Although the literature on psychological readiness among skiers is sparse (and to our best knowledge nonexistent among snowboarders), cognitive, affective and behavioral components of psychological readiness have been found in past research. Cognitive elements such as confidence in performance capabilities, risk appraisals, readjusting expectations, and internal and external pressures to RTS have been documented.
16
,17
For instance, Bianco17
and Gould16
highlighted the importance of having confidence in one's performance capabilities, particularly in the first year following a return to the slopes. One skier in Bianco and colleagues17
study remarked: “You cannot lose confidence in that 1-year period that you have to give yourself postinjury. It's a really frustrating time, because physically you feel 100%, but your body is just not responding. You have to go through the competitive season without getting frustrated, without losing confidence and wanting to quit.” Additionally, skiers articulated risk appraisals regarding the need to be ‘okay’ with the inherent risks of returning to the slopes and indicating a need to “making sure you are OK on skis”.16
The risk of losing one's spot on the team was also an overriding concern for many skiers prompting them to return. Reflecting this concern, a skier noted, “I was never guaranteed a spot (on the team), so I knew I had two chances, two races to qualify for the Olympics, and the whole experience was humiliating because I had no confidence. I had a torn ACL. I couldn't really go for it. . . it was just ugly.”16
Conversely, other skiers reported different risk-calculus decisions, learning from the mistakes of others: “I always asked the doctor if l could ski. I've seen too many people come back from injuries too soon and get injured again. I wanted to make sure that wasn't going to happen to me.”17
Skiers also highlighted the importance of re-adjusting goals and expectations during the initial return to the slopes. Epitomizing this sentiment, one skier remarked, “Maybe I just expected too much of myself. . . I just wasn't emotionally ready for that and maybe I just tried too hard, rather than just relaxing and racing like I normally do.”
16
Finally, skiers highlighted internal and external pressures to RTS. As one skier remarked: “Damned if I was going to miss another Olympics!” As another athlete explained, circumstances were sometimes such that the skiers were unable to do what they knew was right: “Sometimes your competitive schedule doesn't coincide with your recovery schedule, and you have to compete. Athletes feel like they have to do it. And you take that chance sometimes.”From an affective (emotional) standpoint skiers expressed anxieties regarding re-injury, a prominent concern indicative of lower levels of psychological readiness.
16
, 17
, 18
For example, one skier stated: “You get scared to just let things go and go for it and not have that fear of 'Oh God, I could get hurt again.' That alone takes a really long time to get over . . . some girls are good at it. But for me, it took awhile . . . I think it took . . . I am just now back to where I was and you know, it's been three or four year.” Another skier remarked, “I remember starting to fall and I just went into a ball. I thought "Oh my God," and boom, I went over like the time I had crashed, and I thought "Oh geez, here I go again!" But I got up and I was all right and that's the first time I thought, "Geez, I'm really scared to do this again.”16 Anxiety regarding performance capabilities and/or re-injury can compromise attentional control,34
, 35
, 36
, 37
which would likely influence a ski/snowboard racer's ability to process information effectively and efficiently. For example, a skier who is concerned with sustaining an injury is more likely to reinvest mental resources towards consciously controlling their behavior (see Theory of Reinvestment)38
an effect which has been increasingly documented in older adults at risk for falls during walking and other daily activities.39
,40
For ski and snowboard racers, anxiety-induced deviations in attentional control can undermine the fluid execution of skilled movements (e.g., quick body positions changes on substantial incline/slope at great speeds) that have been practiced to a point of automaticity.41
Within these temporally constrained performance environments, athletes should instead devote available perceptual-cognitive resources towards monitoring their speed, processing proprioceptive and biomechanical feedback, and adjusting technique and tactics to account for changes in environmental conditions.42
The ultimate result of re-injury anxiety-induced maladaptive perceptual-cognitive processes are deficits in a skier or snowboarder's ability to engage in and sustain effective goal-directed behaviors. In this vein, various behavioral components of psychological readiness have been documented. For example, skiers commented that their initial return to the slopes was characterized by hesitant or indecisive movements, particularly among those who rushed their return to competition. “In downhill, when you're going 85 miles an hour, you have to be wanting to go 85 miles an hour if you're going to be fast . . . if you're going to do it well. And I think that subconsciously, a little bit, I was holding back. I mean, I really tried. I was trying as hard as I could to go fast, but I think there was just a little something about being injured. I think that went away, but slowly. I mean, I didn't really ski that well that whole next year. . . . I don't think I ever regained the form that I had even the next year.”
16
Biopsychosocial Factors Influencing Psychological Readiness
In order to consider the myriad factors that foster or thwart psychological readiness, it is instructive to have a guiding framework. Biopsychosocial models have demonstrated utility in understanding factors associated with psychological readiness to RTS after injury.
15
,22
In particular, biological and/or physical, behavioral, psychological and social factors may each have beneficial or deleterious implications for skiers’ and snowboarders’ psychological readiness to RTS. Biological factors such as injury healing and enhanced physical function may contribute to or thwart psychological readiness.15
,43
For instance, Caron23
found that greater symptom resolution among concussed athletes (e.g., lack of headaches) facilitated perceptions of readiness to RTS following concussion. Further, Suzuki43
found that limb symmetry index (LSI) of quadriceps strength at 3 and 9 months, and knee extension ROM deficit (>5°) at 3 and 9 months were associated with ACL-RSI scores at 9 months (p < 0.05) among 78 patients undergoing ACL reconstruction. Age and LSI of quadriceps strength at 3 months remained significant predictors of ACL-RSI scores at 9 months in multiple regression analysis (R2 = 0.20, p < 0.001). The researchers concluded that early improvements in quadriceps strength after ACL reconstruction may have a positive impact on psychological readiness at 9 months postoperatively. Similarly, Aizawa et al., found that higher subjective running ability and greater limb symmetry in the lateral single leg hop test were positively associated with psychological readiness among 30 individuals undergoing ACL reconstruction.Behavioral factors, in particular rehabilitation adherence – that is, the extent to which athletes engage in recommended rehabilitation exercises and/or comply with activity restrictions – may also contribute to and/or undermine perceptions of psychological readiness. Although researchers have yet to directly examine links between adherence and psychological readiness, past research has shown that adherence is associated with enhanced physical function, the latter of which is predictive of greater psychological readiness.
43
Other behaviors such as goal setting and recording positive gains in rehabilitation may also facilitate psychological readiness. Goal setting has been shown to be an effective intervention facilitating sport injury rehabilitation outcomes and perceptions of attainment may enhance psychological readiness.45
Psychological factors such as personality traits (e.g., hopefulness, resilience, conscientiousness, neuroticism, internal locus of control) and recovery motivation–both of which have been shown to impact rehabilitation outcomes–are also likely contributors to skiers and snowboarders’ psychological readiness. Illustrative of the impact of personality traits on readiness are empirical findings pertaining to injured athletes’ tendency towards hopefulness. Hope refers to the ability to conceive of a pathway towards one's recovery goals (pathway thinking) and the confidence to take the required steps (agency thinking). Lu and Hsu
47
found that both agency and pathway thinking were positively associated with greater perceptions of treatment efficacy, self-efficacy, and rehabilitation value. Put differently, athletes who believed there was a path towards achieving their rehabilitation goals and felt they had the personal abilities to achieve such goals, were more likely to believe in the effectiveness of their treatment, had greater confidence in achieving rehabilitation goals, and saw the benefit of engaging in a rehabilitation regimen. Additionally, athletes higher in agency thinking had greater rehabilitation adherence. Presumably high-hope athletes would also feel greater psychological readiness at the completion of their rehabilitation, a contention requiring further investigation.Caron
15
revealed that, motivation to return to sport and/or to report or avoid reporting symptoms of concussion featured prominently in athlete's readiness to RTS. Similarly, studies with athletes with MSKI in various sports have found that motivation – both in terms of the quantity and quality (i.e., the reasons why athletes are energized to RTS) may have bearing for the effectiveness of their RTS. For instance, in a survey-based study with 180 competitive level athletes from Canada, England and Australia who RTS following injury, Podlog and Eklund48
found that intrinsic motivation (e.g., a love of the game, a desire to master skills) to resume sport participation was associated with “a renewed sport perspective”; that is, positive perceptions of the RTS. Moreover, extrinsic motivations to RTS (returning for monetary rewards, status or to avoid negative consequences such as internal guilt) were associated with “return to sport concerns”, that is, more negative perceptions of the RTS. These findings indicate that different motivations to RTS may also be implicated in athletes’ psychological readiness. Additional research examining this assertion is warranted.Finally, social influences such as the quality of interactions between injured athletes and various stakeholders (coaches, teammates, sport medicine providers, parents), feelings of isolation and the effectiveness (or lack thereof) of social support may all influence skiers’ and snowboarders’ psychological readiness. Caron
15
found that trust in rehabilitation providers and support from coaches and teammates (e.g., “checking in on athlete's”, lending a listening ear, providing reassurance) were believed to enhance concussed athletes’ readiness while isolation during rehabilitation was reported to detract from athletes’ readiness to RTS. Similarly, relevant others such as parents, may exert a profound impact on athletes’ psychological readiness, particularly in the case of adolescent athletes, where tensions between youth desire − and their potential readiness to RTS −and hesitation and worry on the part of parents may influence the child's sense of readiness. The opposite may also be the case, when for example, a child may indicate a lack of psychological readiness, but parents pressure the youth athlete to return for competition or success reasons.49
These suggestions require further empirical scrutiny.Implications of Psychological Readiness & Future Research Directions
A key question of relevance for researchers and sport medicine providers, is “does psychological readiness predict key clinical and performance outcomes for skiers and snowboarders?” Research undertaken with a variety of athlete populations, suggests the preliminary answer to this question is “yes”. Cross-sectional and longitudinal studies have found that greater psychological readiness is predictive of mental health,
25
physical function,50
,51
the likelihood of returning to pre-injury competitive levels22
,52
,53
and re-injury.54
,55
For instance, Erickson50
found that ACL-RSI scores measured at 3 months post-ACL reconstruction positively correlated with International Knee Documentation Committee score (IKDC; r = 0.565, p = .001), Knee Injury and Osteoarthritis Outcome Score (KOOS) sport/ recreational activities (KOOSSport; r = 0.548, p = .002), quality of life (KOOSQoL; r = 0.431, p = .017), and quadriceps strength (r = 0.528, p = .003) measured at 6 months post ACL reconstruction. Similarly, Hart56
found that lower psychological readiness scores on the ACL-RSI were associated with poorer patient-reported function, assessed via the KOOS function in sport and recreation subscale (β = .28; 95% CI, 0.14–0.41) and the IKDC Subjective Knee Evaluation Form (β = .30; 95% CI, 0.21–0.38), as well as performance-based function (β = 0.14; 95% CI, 0.03–0.25). Further, Slagers53
found that psychological readiness measured at 6 (β = −0.88; 95% CI, −1.48 to −0.28) and 12 months (β = −1.52; 95% CI, −2.01 to −1.02) after achilles tendon rupture had significant associations with sports participation and performance at 12 months post-injury.Original studies and literature reviews have also found that higher levels of psychological readiness are associated with a greater likelihood of return to previous sport activities and/or competitive levels.
22
,29
,- Gerometta A
- Klouche S
- Herman S
- Lefevre N
- Bohu Y.
The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability.
Knee surgery, sports traumatology, arthroscopy. 2018; 26: 203-211
52
Finally, lower levels of psychological readiness are predictive of re-injury or secondary injury upon RTS.54
,55
McPherson55
found that among 329 patients who returned to sport after ACL reconstruction (ACLR), 52 (16%) sustained a second ACL injury. Although no statistically significant difference in psychological readiness was observed at the preoperative time point, patients who sustained a second injury trended toward lower psychological readiness at 12 months compared with non-injured patients (60.9 vs. 67.2 points; p = .11).55
In summary, findings from this narrative review underscore the clinical and functional relevance of psychological readiness. More research however, is needed on a variety of accounts. First, it would be instructive to examine the specific elements or components of psychological readiness among skiers and snowboarders and to examine potential differences in psychological readiness across the various disciplines given their diverse nature. In particular, the definition proposed by Podlog et al.
23
requires further investigation among skiers and snowboarders to determine whether the components articulated capture the full breadth of what it means for such athletes to be mentally ready. Second, further psychometric evaluation regarding the age-appropriateness of existing – or potentially new measures – is warranted. As indicated, it is unclear if existing psychological readiness measures can be used with pediatric populations. Second, work is needed to develop powerful biopsychosocial models to better understand what facilitates and/or thwarts psychological readiness. To this end, we advocate longitudinal, mixed-methods investigations capturing key factors predictive of psychological readiness. Third, further research is needed to determine whether readiness and associated factors might be different among athletes with musculoskeletal injury and concussion. Fourth, experimental studies are needed to examine the efficacy of interventions aimed at augmenting psychological readiness. Fifth, additional research is needed to determine potential implications of psychological readiness, that is to determine whether psychological readiness predicts salient RTS outcomes such as return vs. non-return, re-injury, or post-injury ski and snowboard performances (e.g., race times, competition scores). Such work would be instructive in better understanding what practitioners should do with the information obtained from assessment of psychological readiness. For example, more work is needed to determine what actions practitioners should take (e.g., hold an athlete out of training/competition for a certain period) depending upon results of psychological testing. While further research on psychological readiness is needed, it is evident that assessment of skiers’ and snowboarders’ mental status prior to and/or during the initial (6 months to 1 year) return to the slopes is imperative in ensuring safe and effective resumption of competitive activities.Funding and Conflicts of Interest
The authors have no funding to report for this narrative review and no conflicts of interest that would influence this study or the accurate reporting of the findings.
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Article info
Publication history
Accepted:
February 18,
2023
Received in revised form:
February 15,
2023
Received:
February 1,
2023
Publication stage
In Press Accepted ManuscriptFootnotes
Submitted to: The Journal of Cartilage and Joint Preservation
Consent for Publication: The authors consent to publish these data.
Acknowledgements: N/A
Disclaimer: Dr Fraser reports grants from Congressionally Directed Medical Research Programs and the Office of Naval Research, outside of the submitted work. In addition, Dr Fraser has a patent pending for an Adaptive and Variable Stiffness Ankle Brace, U.S. Provisional Patent Application No. 63254,474. JJF and BF are military service members or employees of the U.S. Government. This work was prepared as part of their official duties. Title 17, U.S.C. §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C. §101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person's official duties. Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, nor the U.S. Government. The investigators have adhered to the policies for protection of human subjects as prescribed in AR 70–25
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© 2023 The Author(s). Published by Elsevier B.V. on behalf of International Cartilage Regeneration and Joint Preservation Society.
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