Physical Therapy in Sport 11 (2010) 23–29

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original research

A preliminary development of the Re-Injury Anxiety Inventory (RIAI)

Natalie Walker a, *, Joanne Thatcher b, David Lavallee b
a
University of Northampton, Park Campus, Boughton Green Road, Northampton, Northamptonshire NN2 7AL, United Kingdom
b
Aberystwyth University, Carwyn James Building, Penglais Campus, Aberystwyth, Ceredigion SY23 3FD, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The present paper outlines the initial development of an instrument to measure re-injury
Received 21 February 2009 anxiety.
Received in revised form Methods: Face, content and factorial validity were examined over three stages of exploratory factor
7 September 2009
analyses.
Accepted 14 September 2009
Participants: 248 injured sport participants completed the scale.
Results: A 28-item measure was produced to measure re-injury anxiety, comprising of two factors: re-
Keywords:
injury anxieties regarding rehabilitation (RIA-R: 15 items) and re-injury anxieties regarding returning to
Re-injury anxiety
Fear of re-injury training/competition (RIA-RE: 13 items). These two factors accounted for 80.56% of the total variance.
Re-Injury Anxiety Inventory The internal consistency for both factors was above the .70 criterion value; rehabilitation re-injury
Psychological assessment anxiety (alpha ¼ .98); re-entry into competition re-injury anxiety (alpha ¼ .96).
Conclusions: Future research needs to test the proposed 2-factor model presented in the current research
using confirmatory factor analysis.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction and psychological changes that impact on performance and ulti-

mately increase the risk of actual injury (Heil, 1993). Psychological
It has increasingly been recognised that physical and psycho- changes are suggested to include both skill-based (e.g., diminishing
logical readiness to return to sport following injury are not concentration and increasing distractibility; Heil, 1993) and inter-
synonymous (Crossman, 1997; Ford & Gordon, 1998; Podlog & pretive changes (e.g., decreasing self-confidence and increasing
Eklund, 2006). Anecdotal and clinical reports indicate that an pain awareness; Heil, 1993). Physiological changes are suggested to
injured athlete tends to have fears or anxieties about re-injury include muscular (e.g., generalised muscular tension and guarding
(Andersen, 2001; Bianco, 2001; Bianco, Malo, & Orlick, 1999; Cas- the injured site; Heil, 1993) and autonomic changes (e.g., over-
sidy, 2006; Driediger, Hall, & Callow, 2006; Gallagher & Gardner, arousal evident through increased heart rate and neurochemical
2007; Gould & Udry, 1994; Gould, Udry, Bridges, & Beck, 1997; Heil, changes; Heil, 1993).
1993; Johnston & Carroll, 1998; Kvist, Ek, Sporrstedt, & Good, 2005; The athlete who fears injury is said to be preoccupied with the
Podlog & Eklund, 2005, 2006; Tripp, Ebel-Lam, Stanish, & Brewer, physical sensations arising from the injured site or with slight
2007). Johnston and Carroll (1998) stated that fear of re-injury was reductions in performance (e.g., brief loss of balance; Andersen &
the predominant emotion associated with returning to sport Williams, 1988; Feltz, 1986; Petitpas & Danish, 1995; Rotella &
following sporting injury. The way athletes appraise the risk of Heyman, 1986; Williams & Roepke, 1993). These are suggested to
returning to sport has been recognised as an important component affect performance through decreased efficiency in the biome-
of injury rehabilitation (Johnston & Carroll, 1998). Hägglund, Wal- chanics of skill execution, poor use of energy resources, and
dén, Bahr, and Ekstrand (2005) stated that re-injury is usually decreased attention (Heil, 1993). These performance effects/detri-
defined as ‘‘an injury occurring after an initial injury of the same ments may then bring about a mutually reinforcing, self-perpetu-
type and location’’. ating cycle and increase the risk of injury (Heil, 1993; Williams &
Heil (1993) speculated that fear of injury is always present for all Andersen, 1998).
athletes. It is suggested that fear of injury results in physiological Although Heil (1993) presented this idea regarding fear of injury
the same process can be assumed to relate to re-injury. Fear of re-
injury is suggested to produce psychological decrements such as
* Corresponding author. Tel.: þ44 1604 892490.
reduced confidence and poor focus that inhibit progression in the
E-mail addresses: [email protected] (N. Walker), [email protected]. return to sport (Chase, Magyar, & Drake, 2005; Taylor & Taylor,
uk (J. Thatcher), [email protected] (D. Lavallee). 1997; Tripp et al., 2007). Taylor and Taylor (1997) also suggest that

1466-853X/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2009.09.003
24 N. Walker et al. / Physical Therapy in Sport 11 (2010) 23–29

re-injury fears cause the same physiological changes proposed by regarding sources of danger and therefore there are actions of
Heil (1993) which are likely to increase the risk of actual re-injury. escape. Walker (2006) identified that the injured case participants
Taylor and Taylor (1997) stated that fear of re-injury develops from did not discuss escape actions, despite being anxious about re-
a lack of trust in the injured site. They suggested that this lack of injury during rehabilitation and on return to training and compe-
confidence and trust can influence the onset of re-injury via the tition. For example, all case participants continued to engage in
mechanisms proposed by Heil (1993) and produce a hesitant/ rehabilitation activities throughout the programme, although often
tentative performance in rehabilitation and on return to training/ with some hesitation.
competition, a proposal also suggested by Chase et al. (2005), Injury is a definite danger in sport but there is no certainty or
Johnston and Carroll (1998), and Petitpas and Danish (1995). clarity regarding the extent of injury risk and the character of
Hesitancy will produce a substandard performance that will injury situations. Therefore, athletes associate the risk of injury
perpetuate the cycle, and doubts will cause decreased co-ordina- with situations of varying general characteristics and degrees of
tion and increased muscle tension and bracing (Gould & Udry, 1994) uncertainty (Kleinert, 2002). This implies that perceived injury
that are suggested to increase actual re-injury occurrence. risk is individual and dynamic, and is a different experience of
Based on anecdotal evidence, Taylor and Taylor (1997) stated each athlete, for any given situation and time. As a high degree of
that on return to competition athletes often report being ‘rusty’ and ambiguity remains regarding injury situations and the injury itself,
are challenged to return to the comfort and ease of skill execution a more accurate term appears to be re-injury anxiety rather than
that was evident prior to injury, also suggested by Podlog and fear of re-injury. Moreover, Kleinert (2002) states that injury-
Eklund (2006) and Rotella and Heyman (1986). The injured athlete related concerns and anxieties are in many respects not funda-
is often preoccupied with the details of technique to the detriment mental or biological, but result from previous experience (e.g., the
of natural feelings associated with well-practised and learnt skills original injury experience) and other developmental factors (e.g.,
(Taylor & Taylor, 1997). Kvist et al. (2005) stated that many indi- quality of rehabilitation). This kind of emotional development is
viduals complain that their performance was worse after compared more typical of anxiety than fear (Kleinert, 2002). Hence, in
to before the injury and that re-injury anxieties may influence striving for conceptual clarity, the term re-injury anxiety is
injured athlete’s not returning to their sport. perceived by the present authors to be more appropriate than fear
It must be noted that much of the literature to date on fear of re- of re-injury.
injury or re-injury anxiety is anecdotal, including the causal rela-
tionships discussed above. Walker (2006) explored the longitudinal 1.2. Measuring re-injury anxiety
responses to athletic injury in three case participants. Using
phenomenological interviews to explore the meaning of injury, the Brewer (2001) comments that the development of psychological
research identified that re-injury concerns were a universal measures specific to the sport injury rehabilitation setting will help
response amongst all case participants through rehabilitation and to provide researchers with standardised instruments and enable
on return to training and competition. These worries appeared to specific research questions to be answered. The use of standardised
reflect anxiety as opposed to fear as indicated in some reports psychometric tools allows researchers to measure the same
(Bianco, 2001; Bianco et al., 1999; Johnston & Carroll, 1998; Kvist construct in the same way and obtain reliable results. A lack of
et al., 2005; Podlog & Eklund, 2005, 2006). It is worthwhile to note appropriate measures by which athletes’ responses to injury may
that the majority of studies do not offer conceptual clarification be accurately assessed has required a reliance on nonpopulation
when discussing re-injury anxiety or fear of re-injury. specific measures (Brewer, 2001; Evans, Hardy, & Mullen, 1996;
Evans, Mitchell, & Jones, 2006). As a result of relying on non-
1.1. Conceptual clarity: fear of re-injury or re-injury anxiety? population specific measures they may lack content and predictive
validity (Evans, Hardy, Mitchell, & Rees, 2008). The development
Fear of re-injury (Heijne, Axelsson, Wener, & Biguet, 2008; Kvist and use of appropriate injury specific measures is vital in order to
et al., 2005; Rotella & Campbell, 1983; Tripp et al., 2007) and re- assess relevant constructs, such as re-injury anxiety, and answer
injury anxiety (Cassidy, 2006; Castillo, Cremades, & Butcher, 2002; significant research questions (Brewer, 2001; Evans et al., 2006).
Cupal & Brewer, 2001; Short, Reuter, Brandt, & Short, 2005) are Given the potential implications of re-injury anxiety on perfor-
commonly mentioned in the sport psychology literature but mance and psychological readiness during rehabilitation, return to
authors rarely define their conceptual framework (Cassidy, 2006; training, return to competition, and the increased likelihood of
Kleinert, 2002). actual re-injury, it is important to address coping strategies and
Hackfort and Schwenkmezger (1993) summarised the fear- interventions that could be employed to assist athletes in managing
anxiety debate and stated that fear is a fundamental biological their re-injury anxieties. The development of a valid and reliable
mechanism, whereas anxiety is composed of different elements instrument to measure re-injury anxiety would enhance the
(e.g., cognitive and somatic) and is associated with learning and understanding of this little understood construct, its develop-
social processes. Fear is defined as being stimulus-specific and is mental patterns, and facilitate research to assess the efficacy of
associated with definite danger whereas anxiety is connected to the coping strategies and interventions to address re-injury anxiety.
anticipation and imagination of ambiguity and uncertainty. However, at present there is no valid and reliable means of
Therefore anxiety is more a feeling of what might happen and not measuring re-injury anxiety and the lack of such a tool presents
a response to an obvious fear-provoking situation. Walker (2006) limitations to current research on re-injury anxiety. Previous
reported that case participants thought about their injury reoc- research has tended to employ single-item Likert type scale
curring during rehabilitation exercises, functional rehabilitation measures (Cupal & Brewer, 2001) or employ other instruments,
exercises, and on return to training and competing. The case such as the Competitive State Anxiety Inventory-2 (CSAI-2;
participants experienced feeling images of the injury and these Martens, Vealey, & Burton, 1990), that are designed to measure
images were played over in their minds. The case participants also other constructs and not re-injury anxiety. For example, Castillo
felt nauseous, sweaty, and tense. These symptoms represent et al. (2002) used the CSAI-2 to measure re-injury anxiety when in
cognitive (e.g., negative thoughts, and worry) and somatic (e.g., fact the CSAI-2 measures competition anxieties. Therefore, the aim
physiological response) anxiety as opposed to fear. Hackfort and of the current study was to develop a scale which measures re-
Schwenkmezger (1993) identified that with fear there is certainty injury anxiety.
 N. Walker et al. / Physical Therapy in Sport 11 (2010) 23–29 25

2. Method were suggested including rewording repetitive items (Form F). Form
F was administered to injured athletes (N ¼ 8) for item compre-
2.1. Overview of stages of development hension using an item comprehension questionnaire developed for
the purpose of the study. Athletes were sampled from a range of
2.1.1. Stage 1: item development sports and all were participating in rehabilitation programmes at the
Re-Injury Anxiety Inventory (RIAI) items were initially gener- same rehabilitation clinic. Athletes had sustained moderate to
ated by adapting the CSAI-2 items. This decision was based on the severe injuries across a range of sites and were in various stages of
suggestion by Cupal and Brewer (2001) to use an existing multi- rehabilitation. 75% of the sample stated that they did not understand
item tool for development. This will go someway to overcome the some of the 54 items. They reported that some items were lengthy
limitations inherent with single-item scales. The CSAI-2 was and unclear, hence adaptations were made to combat these issues
selected as a suitable instrument on which to begin the initial (Form G). Form G, a 54 item instrument, was administered to injured
development of the RIAI as injured athletes have appeared to sports participants to assess the instrument’s construct/factorial
express anxiety related emotions when discussing their injury validity. A set of anti-social desirability instructions were taken and
concerns (Cassidy, 2006; Walker, 2006). Many responses to athletic modified from the CSAI-2 and used when administering Form G to
injury, including re-injury anxiety, are reported to be transient the injured sports participants.
(Granito, 2001; Johnston & Carroll, 1998) and are influenced by
dynamic factors (e.g., length of time in rehabilitation, severity of 2.1.3. Stage 3: construct/factorial validity
injury) (Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998). Therefore, Using the maximum likelihood extraction method of explor-
it was deemed appropriate to measure re-injury anxiety as a state atory factor analysis (EFA), with oblimin rotation, the instrument’s
construct rather than one that is stable over time, hence, providing initial construct/factorial validity was examined.
further justification for the initial use of the CSAI-2. Furthermore,
Walker (2006) identified that injured athletes discussed cognitive 2.2. Participants
and somatic symptoms in response to re-injury concerns and
described reductions in re-injury anxiety in relation to increased 248 injured sport participants (126 females, 132 males) aged
self-confidence as the number of successful weeks without actual 17–39 years (M ¼ 26.44, 5.86 years) completed adaptation seven
re-injury increased. The inclusion of items related to these three of the scale (Form G). This provided almost a 5:1 participant to item
constructs (i.e., self-confidence, cognitive and somatic anxiety) ratio. Guadagnoli and Velicer (1988) stated that an N of 150 was
therefore adds to the argument of using the CSAI-2 as a basis from sufficient for 40 or 50 items on an inventory, a ratio of 3:1. Gorsuch
which a measure of re-injury anxiety can be developed. (1997) suggested that 200–300 participants are suitable for
Stage 1 involved rewording and modifying the CSAI-2 items to assessing an instrument’s construct/factorial validity. However,
reflect re-injury anxiety rather than competitive state anxiety they did suggest examining Bartlett’s test of significance as a safe-
(Form A). Following the suggestions of Lane, Sewell, Terry, Bartram, guard. The results of Bartlett’s test of Sphericity (p < .05) indicated
and Nesti (1999) a second adaptation was produced, where all that the sample size was sufficient.
items were reworded using the term ‘worried’ (Form B). Lane et al. Criteria for inclusion required that participants had sustained an
(1999) identified that at stage 5 of the CSAI-2 development the injury as a result of sports participation and were currently
term ‘worried’ was replaced with the term ‘concerned’ to reduce receiving sports injury treatment from a qualified Sports Therapist
the influence of social desirability. The semantic difference or Physiotherapist. The volunteers participated in several sports,
between these two words however may have threatened the including association football (n ¼ 96), rugby league (n ¼ 67), rugby
conceptual integrity of the scale. An athlete may be concerned union (n ¼ 47), martial arts (n ¼ 16), field hockey (n ¼ 10), swim-
about something but may not necessarily be anxious. Therefore, the ming (n ¼ 6), and triathlon (n ¼ 6). They competed at different
term ‘worried’ was used in development of the re-injury anxiety levels including club level (n ¼ 127), University level (n ¼ 78), semi-
measure. professional (n ¼ 10), professional (n ¼ 17), and national (n ¼ 16).

2.1.2. Stage 2: item suitability, face and content validity 2.3. Procedure
Scrutiny of the items in Form B took place by experts in the field
(N ¼ 2) for item suitability, face and content validity. The experts The RIAI was administered to athletes within 30 min prior to
were both Sport Psychologists with experience in inventory devel- a participant’s rehabilitation session. The athletes were told to read
opment. Suggested modifications were made based on grammar the instructions at the head of the RIAI and to complete the
and separating items that attempted to measure both re-injury instrument as directed indicating their agreement/disagreement
anxieties about rehabilitation and re-entry into competition (Form with each statement regarding how they felt at that moment.
C). Form C underwent further scrutiny by Sport Therapy personnel
(N ¼ 2). These personnel suggested modifying the Likert scale from 2.4. Data analysis
1–4 to 0–3 to accommodate the absence of any anxiety (Form D).
Form C used a 1–4 Likert scale with descriptors ‘‘not at all’’ and ‘‘very Using the maximum likelihood extraction method of explor-
much so’’ representing opposite ends of the scale. The modified atory factor analysis (EFA), with oblimin rotation, the instrument’s
Form D used the same descriptors to represent the opposite ends of initial construct/factorial validity was examined. EFA has been
a 0–3 scale. Form D underwent further scrutiny by Sports Physio- widely used as a technique in the initial development of inventories
therapy personnel (N ¼ 2). It was suggested that all items should (1997). EFA was deemed appropriate at this stage as Gorsuch (1997)
explore anxieties regarding rehabilitation and re-entry into stated, ‘‘confirmatory factor analysis requires clear predictions as to
competition and not only some items. This increased the inventory which factors exist, how they relate to the variables and how the
from 31 to 54 items. Furthermore, rewording suggestions (e.g., relate to each other’’. Without these predictions, as in the current
clammy changed to sweaty) were made to improve the clarity of the study, EFA are required initially. EFA was utilised opposed to prin-
items and make the inventory more universally understood (Form ciple component analysis because EFA takes into account an error
E). Form E was scrutinised by a further expert in the field who was term (Gorsuch, 1983) and therefore assumes that the, ‘‘variables
experienced in inventory development (N ¼ 1). Formatting changes are conceptualised as reproduced perfectly by the factors’’
26 N. Walker et al. / Physical Therapy in Sport 11 (2010) 23–29

(Gorsuch, 1997). Maximum likelihood extraction is the preferred Gorsuch (1997), following the removal of items further maximum
extraction method (Fabrigar, Wegener, MacCallum, & Strahan, likelihood extraction analyses, with oblimin rotations, were con-
1999). This method allows the computation of assorted indices of ducted (N ¼ 2). Internal consistency of the factors was assessed
goodness of fit, of the data to a model, and the testing of the using Cronbach’s (1951) alpha. An alpha coefficient for an internally
significance of loadings and correlations between factors. With consistent scale should be al least .70 (Tabachnick & Fidell, 1996).
regards to rotations there is a strong preference for oblique rota-
tions as opposed to orthogonal solutions (Fabrigar et al., 1999). If 3. Results
latent variables are correlated then an oblique rotation, such obli-
min rotation, is suggested to produce a better estimate of the true The analysis revealed a two-factor structure accounting for
factors and a better factor structure than an orthogonal rotation 80.56% of the total variance (56.42% and 21.13% respectively). The
(Fabrigar et al., 1999). various indicators of factoriability were good, and the residuals
The number of factors produced is initially identified by eigen- indicated that the solution was good. The Kaiser–Meyer–Olkin
values greater than 1.00 as a measure of how much variance in all (KMO ¼ .857) indicates good factoriability (Brace et al., 2003) and
the data is explained by a single factor (Brace, Kemp, & Snelgar, Bartlett’s test of Sphericity (p < .05) indicates that the data appear
2003). Salient factors were then identified by exploring where to be factoriable (Brace et al., 2003). Within these two factors there
items loaded greater than .50 on the structure matrix output are two items that have negative loadings (see Table 1). These items
(Vlachopoulos, Karageorghis, & Terry, 2000) and where a factor had are negatively worded, hence require reverse scoring. Items were
the highest loading for this item (Gorsuch, 1997). Dual loading removed from factor 1 following the guidelines outlined previously.
items, where item loadings were greater than .50 on more than The content of these items were related to re-injury anxiety in
one factor and item loadings on >2 factors that were within .100 of rehabilitation (RIA-R). All items loading onto factor 2 were related
each other, were removed. Dual loading items were ambiguous and to re-injury anxiety regarding re-entry into competition (RIA-RE).
as there were a total of 54 items it was deemed appropriate to
remove ambiguous items and reduce the total number of items to 3.1. Internal consistency
a more manageable number for injured athletes to read and score
in the final scale. Where a factor was only comprised of one or two The internal consistency for both factors was above the .70
items and/or had dual loadings with items loading higher on other criterion value (Nunnally & Bernstein, 1994; Tabachnick & Fidell,
salient factors the factor was removed, as suggested by Gorsuch 1996); rehabilitation re-injury anxiety (alpha ¼ .98); re-entry into
(1997) who labelled these trivial factors. As recommended by competition re-injury anxiety (alpha ¼ .96).

Table 1
Final factor structure with corresponding item loadings.

Factor

Rehabilitation Re-entry into competition

re-injury anxiety re-injury anxiety
I am worried about becoming re-injured during rehabilitation .965
I am worried about becoming re-injured during re-entry into competition .980
I feel nervous about becoming re-injured during rehabilitation .989
I feel nervous about becoming re-injured during re-entry into competition .959
I have doubts that I will remain injury free during rehabilitation .924
I have doubts that I will remain injury free during re-entry into competition .899
I feel on edge about becoming re-injured during rehabilitation .930
I feel on edge about becoming re-injured during re-entry into competition .881
I am worried that I may not do as well as I could in rehabilitation .975
due to re-injury worries
I am worried that I may not do as well as I could on returning to competition .895
due to re-injury worries
My body feels tense about rehabilitation because of re-injury worries .934
My body feels tense about re-entering competition because of re-injury worries .867
I feel confident that I will not become re-injured during re-entry into competitiona .813
I am worried about failing during rehabilitation due to my re-injury worries .969
I am worried about failing when re-entering into competition due to re-injury worries .945
Re-injury worries about rehabilitation make my body feel tense .970
Re-injury worries about re-entry into competition make my body feel tense .889
I am worried about performing poorly during rehabilitation due to re-injury worries .931
I am worried about performing poorly during re-entry into competition .895
due to re-injury worries
I am worried about failing to achieve full re-entry into competition due to re-injury worries .856
I feel my stomach sinking due to re-injury worries during rehabilitation .852
I am worried that others will be disappointed if I become re-injured .805
during re-entry into competition
The thought of re-injury during re-entry into competition makes my palms sweaty .834
I am confident about not becoming re-injured during rehabilitation because .546
I mentally picture myself staying injury freea
I am worried about concentrating during rehabilitation because of re-injury worries .838
I am worried about concentrating during re-entry into competition .669
because of re-injury worries
My body feels tight due to re-injury worries during rehabilitation .928
My body feels tight due to re-injury worries during re-entry into competition .861
a
Item requires reverse scoring (e.g., 0 would score 3, 1 would score 2, 2 would score 1, and 3 would score 0).
 N. Walker et al. / Physical Therapy in Sport 11 (2010) 23–29 27

3.2. Independence of the RIAI constructs 4. Discussion

Using the RIAI Form G a second set of data were collected The aim of this study was to develop and conduct an initial
separated by a two week interval from the first data collection. validation of a scale to assess re-injury anxiety in injured athletes.
Significant correlations (p < .05) were identified for between RIA-R This initial study has indicated that the items of the RIAI had good
and RIA-RE constructs. Correlations between the two constructs factoriability. Following three procedures of EFA, where trivial
ranged from .41 to .65 over the two data collection periods factors were removed and salient factors determined the items of
(M ¼ .53). This relationship between the two constructs reflects the RIAI were explained by two constructs (factors) accounting for
that athletic injury elicits both re-injury anxieties in rehabilitation 80.56% of the total variance. After examination of the content of
and re-injury anxieties when re-entering training/competition and these items it was clear that factor one was comprised of items that
both constructs are somewhat related. related to rehabilitation re-injury anxiety (N ¼ 13) accounting for
56.42% of the total variance. Factor two was comprised of items
3.2.1. Re-Injury Anxiety Inventory (RIAI) related to re-entry into competition re-injury anxiety (N ¼ 15)
The effects of athletic injury can be powerful and very different accounting for 24.13% of the total variance. Hence, the two
among athletes. The inventory you are about to complete measures constructs measured by the RIAI were labelled: rehabilitation re-
how you feel about re-injury at the moment you are responding. injury anxiety (RIA-R) and re-entry into competition re-injury
Re-injury means an injury of the same type and location of anxiety (RIA-RE). The Table below contains the RIAI derived from
a previous injury. Please complete this inventory as honestly as you the current research.
can. Sometimes athletes feel they should not admit to any The final tool is a 28-item multidimensional measure of re-
nervousness, anxiety, or worry they experience regarding re-injury injury anxiety and takes approximately 5 min to complete. Injured
concerns because this is undesirable. Actually, these feelings are athletes are required to read each statement and circle the appro-
quite common, and to help us understand them we want you to priate number indicating how they feel right at that moment in
share your feelings with us candidly. If you are worried about re- time. The RIAI is scored by computing a separate score for the two
injury please indicate these feelings accurately on the inventory. constructs by adding together the scores for the items corre-
Equally, if you feel calm and relaxed, indicate those feelings as sponding to each construct. Scores for items 1, 3, 5, 7, 9, 11, 14, 16, 18,
accurately as you can. Your answers will not be shared with anyone. 21, 24, 25, 27 are added to calculate an athlete’s RIA-R (item 24
We will be looking only at group responses. requires reverse scoring). A minimum score of 0 would indicate
Below are several statements that athletes have used to describe a complete absence of RIA-R and a maximum score of 39 would
their feelings regarding re-injury worries. Read each statement and indicate that the athlete was extremely anxious about re-injury in
circle the appropriate number to indicate how you feel right now, at rehabilitation. Scores on items 2, 4, 6, 8, 10, 12, 13, 15, 17, 19, 20, 22,
this moment (0 ¼ not at all; 1 ¼ somewhat; 2 ¼ moderately so; 23, 26, and 28 are added to calculate an athlete’s RIA-RE (item 13 on
3 ¼ very much so). There are no right or wrong answers, please do this construct also requires reverse scoring). A minimum score of
not spend too much time on any one statement. 0 would indicate a complete absence of any RIA-RE and a maximum

Not at all Somewhat Moderately so Very much so

1.I am worried about becoming re-injured during rehabilitation 0 1 2 3
2.I am worried about becoming re-injured during re-entry into competition 0 1 2 3
3.I feel nervous about becoming re-injured during rehabilitation 0 1 2 3
4.I feel nervous about becoming re-injured during re-entry into competition 0 1 2 3
5.I have doubts that I will remain injury free during rehabilitation 0 1 2 3
6.I have doubts that I will remain injury free during re-entry into competition 0 1 2 3
7.I feel on edge about becoming re-injured during rehabilitation 0 1 2 3
8.I feel on edge about becoming re-injured during re-entry into competition 0 1 2 3
9.I am worried that I may not do as well as I could in rehabilitation due to 0 1 2 3
re-injury worries
10. I am worried that I may not do as well as I could on returning to competition 0 1 2 3
due to re-injury worries
11. My body feels tense about rehabilitation because of re-injury worries 0 1 2 3
12. My body feels tense about re-entering competition because of re-injury worries 0 1 2 3
13. I feel confident that I will not become re-injured during re-entry into competition 0 1 2 3
14. I am worried about failing during rehabilitation due to my re-injury worries 0 1 2 3
15. I am worried about failing when re-entering into competition due to re-injury worries 0 1 2 3
16. Re-injury worries about rehabilitation make my body feel tense 0 1 2 3
17. Re-injury worries about re-entry into competition make my body feel tense 0 1 2 3
18. I am worried about performing poorly during rehabilitation due to re-injury worries 0 1 2 3
19. I am worried about performing poorly during re-entry into competition due 0 1 2 3
to re-injury worries
20. I am worried about failing to achieve full re-entry into competition due 0 1 2 3
to re-injury worries
21. I feel my stomach sinking due to re-injury worries during rehabilitation 0 1 2 3
22. I am worried that others will be disappointed if I become re-injured during 0 1 2 3
re-entry into competition
23. The thought of re-injury during re-entry into competition makes my palms sweaty 0 1 2 3
24. I am confident about not becoming re-injured during rehabilitation because 0 1 2 3
I mentally picture myself staying injury free
25. I am worried about concentrating during rehabilitation because of re-injury worries 0 1 2 3
26. I am worried about concentrating during re-entry into competition because of re-injury worries 0 1 2 3
27. My body feels tight due to re-injury worries during rehabilitation 0 1 2 3
28. My body feels tight due to re-injury worries during re-entry into competition 0 1 2 3
28 N. Walker et al. / Physical Therapy in Sport 11 (2010) 23–29

score of 45 would indicate that the injured athlete was extremely 5. Conclusion
anxious about re-injury in re-entry into training/competition. Both
RIA-R and RIA-RE demonstrated high internal consistency above Prior to the current research no researchers had attempted to
the .70 criterion value (Tabachnick & Fidell, 1996). When exploring develop a valid and reliable tool to measure re-injury anxiety.
the independence of the RIAI constructs a moderate correlation Therefore, there were no a priori predictions as to which constructs
(r ¼ .53) was evident. This reflects that re-injury anxieties con- exist, how they would relate to the items on the inventory, and how
cerning rehabilitation and re-entry are not totally independent the constructs relate to each other. Without these predictions EFA is
constructs. It is therefore likely that an injured athlete exhibiting required (Fabrigar et al., 1999). However, following the present
re-injury anxieties regarding re-entry into competition would have study confirmatory factor analysis (CFA) is now recommended in
some re-injury anxieties during their rehabilitation. order to test the proposed 2-factor model presented in the current
It is accepted that establishing the validity of an instrument is an research. CFA has the advantage of testing the data against
ongoing process (Anastasi & Urbina, 1997). Therefore further a proposed model and the fit of the model is assessed using more
analyses of the RIAI are advocated. It should be noted that items 9, stringent criteria (Lane et al., 1999). Research is ongoing to explore
14, 15, 18–20, 25, and 26 appear to reflect meta-worries (i.e., the RIAI using CFA.
worries about worries).1 For these items respondents are being
asked to perform what seems to be a difficult task, differentiating Conflict of Interest Statement
worries about re-injury from worries about worries from re-injury.
However, during the item comprehension analyses no athlete No author of the current manuscript has any conflict of interest.
reported that they found these items difficult to respond to. These
items could be reworded so not to require respondents to respond Ethical Approval
to meta-worries. This could be explored in further analyses of the
RIAI. It is recommended that the validity of the RIAI is tested further All procedures were approved by the School of Health Ethics
the extent to which findings from the present study are consistent Committee at the University of Surrey, St. Mary’s College.
across samples. Future studies should compare the responses of
severely and non-severely injured athletes, and presently injured
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