Athletic Injury Imagery Questionnaire-2 (AIIQ-2)

Abstract

The Athletic Injury Imagery Questionnaire-2 (AIIQ-2) is an 11-item psychometric self-report instrument designed to assess the frequency and functional dimensions of mental imagery used by athletes during physical injury rehabilitation. Adapted from the original Athletic Injury Imagery Questionnaire developed by Carl Sordoni, Craig Hall, and Lynda Forwell, the revised AIIQ-2 captures three primary latent constructs: Motivational Imagery (3 items), Cognitive Imagery (4 items), and Healing Imagery (4 items). Respondents rate their usage on a 7-point Likert scale ranging from 1 (Never) to 7 (Frequent). Across psychometric investigations, the AIIQ-2 demonstrates robust construct validity, high internal consistency reliability (Cronbach’s alpha coefficients generally ranging from .81 to .92 across subscales), and distinct factorial validity confirmed through exploratory and confirmatory factor analyses. By evaluating how injured athletes mentally rehearse rehabilitation exercises, visualize biological tissue healing, and cope with psychological distress such as anxiety and rehabilitation plateaus, the AIIQ-2 serves as a pivotal measurement tool in sport psychology, athletic training, physical therapy, and behavioral medicine.

Keywords

Athletic Injury Imagery Questionnaire-2, AIIQ-2, sports injury rehabilitation, healing imagery, cognitive imagery, motivational imagery, sport psychology, athletic recovery, motor imagery, rehabilitation self-efficacy

Authors

The original conceptualization and empirical validation of the Athletic Injury Imagery Questionnaire series were conducted by:

• Carl Sordoni, M.A. — School of Kinesiology, The University of Western Ontario, London, Ontario, Canada.
• Craig R. Hall, Ph.D. — Professor Emeritus, School of Kinesiology, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada. Email: [email protected].
• Lynda Forwell, M.Sc., P.T., Dip. Sport P.T., F.C.A.M.P.T. — Professor and Chair of Physical Therapy, Faculty of Health Sciences, The University of Western Ontario; Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.

Subsequent psychometric refinement and evaluation of the healing imagery dimension (AIIQ-2 adaptations) were conducted by:

• Joel M. Cressman, M.Sc. — Department of Kinesiology and Physical Education, Wilfrid Laurier University, Waterloo, Ontario, Canada.
• Kimberley A. Dawson, Ph.D. — Professor of Sport Psychology, Department of Kinesiology and Physical Education, Wilfrid Laurier University, Waterloo, Ontario, Canada.

Purpose

Physical injuries in athletic populations precipitate not only biomechanical and physiological impairments but also profound psychological disruption. Injured athletes frequently confront severe emotional reactions, including post-injury anxiety, depression, loss of athletic identity, fear of re-injury, and diminished self-efficacy regarding rehabilitation. While physical therapy protocols emphasize mechanical loading, range-of-motion restoration, and neuromuscular re-education, psychological skills training—specifically the strategic use of mental imagery—has emerged as a central therapeutic adjuvant.

The primary purpose of the Athletic Injury Imagery Questionnaire-2 (AIIQ-2) is to provide sports medicine practitioners, physical therapists, athletic trainers, and sport psychology researchers with a reliable, empirically validated instrument to measure the multidimensional functions of imagery applied within rehabilitation settings. Specifically, the questionnaire quantifies:

• The frequency with which athletes mentally rehearse physical rehabilitation exercises and adapt neuromuscular strategies (Cognitive Imagery).
• The extent to which athletes mentally simulate emotional self-regulation, coping mechanisms, perseverance through setbacks, and anxiety control during recovery (Motivational Imagery).
• The degree to which athletes actively visualize cellular, vascular, muscular, and connective tissue repair and physiological healing processes (Healing Imagery).

In clinical practice, the AIIQ-2 serves as a baseline diagnostic and ongoing monitoring tool. It allows sports physical therapists and applied sport psychologists to identify athletes who underutilize psychological coping resources, tailor biobehavioral interventions, and measure the efficacy of structured guided imagery protocols. In academic and empirical research, the tool facilitates the investigation of how distinct imagery modalities influence rehabilitation adherence, pain tolerance, self-efficacy, biological healing markers, and return-to-play timelines.

Psychological Construct

The AIIQ-2 operationalizes athletic injury imagery as a tripartite psychological construct consisting of three functionally distinct yet interrelated dimensions. These dimensions are grounded in applied sport psychology models and cognitive neuroscience.

1. Motivational Imagery (3 Items)

Motivational imagery within the rehabilitation context encompasses mental representations related to emotional regulation, distress tolerance, goal pursuit, and psychological endurance. Sport injuries disrupt an athlete’s routine, causing elevated cortisol levels, frustration, and performance anxiety. Motivational imagery enables the athlete to simulate scenarios wherein they successfully manage setbacks (e.g., slower-than-expected recovery or reinjury risks), regulate somatic anxiety, and maintain perseverance. Exemplified by items such as “I imagine coping with the stress associated with my injury” and “I imagine handling the anxiety resulting from my injury,” this construct reflects an internal coping mechanism that reinforces psychological resilience and self-efficacy under adverse conditions.

2. Cognitive Imagery (4 Items)

Cognitive imagery involves the mental rehearsal and cognitive processing of specific motor skills, physical therapy exercises, and tactical rehabilitation plans. Grounded in motor simulation theory, cognitive imagery activates motor programming networks within the central nervous system—including the premotor cortex, supplementary motor area, and cerebellum—without generating overt muscular movement. Items such as “Prior to performing a rehabilitation exercise, I am able to imagine myself completing it perfectly” and “I am able to change the image of a particular rehabilitation skill or exercise if necessary” evaluate both the reproductive capability (mental practice of assigned movements) and cognitive flexibility (modifying movement patterns according to therapist instructions or physiological constraints).

3. Healing Imagery (4 Items)

Healing imagery refers to an internal visualization process wherein the individual generates vivid mental images of internal biological, physiological, and anatomical recovery. Rooted in psychoneuroimmunology and mind-body interventions, healing imagery involves visualizing broken bones knitting, torn ligaments generating collagen fibers, damaged muscles restoring vascularity, or swelling subsiding. Captured by items such as “I imagine my damaged tissue returning to normal” and “I imagine the physiological changes my body is making during recovery,” this construct represents an intentional cognitive effort to stimulate positive expectancies, autonomic down-regulation of the stress response, and subjective engagement in biological repair.

Theoretical Framework

The conceptual foundation of the AIIQ-2 is rooted in several converging paradigms within cognitive psychology, sport psychology, and psychoneuroimmunology.

Paivio’s Analytic Framework of Imagery

The original theoretical architecture traces back to Allan Paivio’s (1985) two-dimensional framework of imagery effects. Paivio posited that imagery operates through two functional levels—cognitive and motivational—each capable of operating at either a specific or general level. This framework was adapted for athletics by Hall, Mack, Paivio, and Hausenblas (1998) in the formulation of the Sport Imagery Questionnaire (SIQ), which distinguished cognitive specific (skills), cognitive general (strategies), motivational specific (goal achievement), motivational general-arousal (affect and stress), and motivational general-mastery (mental toughness and confidence).

When Sordoni, Hall, and Forwell (2000, 2002) transitioned these principles to orthopedic rehabilitation, they recognized that the athletic performance framework required adaptation. Athletic rehabilitation rarely focuses on competitive play strategies; instead, cognitive imagery is applied to technical compliance with therapy regimens, while motivational imagery serves to mitigate recovery distress and promote adherence. Furthermore, rehabilitation introduced a novel physiological dimension not present in healthy performance: the conscious visualization of biological tissue repair, leading to the integration of Healing Imagery.

Psychoneuroimmunology and Motor Simulation Theory

The healing imagery component draws heavily upon the clinical hypnosis and mind-body medicine literature pioneered by Achterberg (1985) and Green and Green. Psychoneuroimmunological theory posits that mental states and guided visualization can modulate sympathetic nervous system activity, down-regulate systemic pro-inflammatory cytokine expression (e.g., IL-6, TNF-alpha), and enhance immune competence, thereby creating an optimal physiological milieu for cellular proliferation and tissue remodeling.

Simultaneously, the cognitive component aligns with Marc Jeannerod’s Motor Simulation Theory (1994, 2001), which asserts that motor imagery represents the subliminal activation of the motor system. Mentally executing a rehabilitation exercise preserves cortical representation in the somatosensory cortex and prevents functional disuse atrophy of neural pathways during prolonged immobilization.

Bandura’s Self-Efficacy Theory

Albert Bandura’s (1997) Self-Efficacy Theory serves as a bridge linking all three dimensions to clinical outcomes. Bandura demonstrated that vicarious experiences and imaginal experiences act as potent sources of efficacy expectations. Athletes who visualize themselves executing exercises successfully (cognitive), navigating rehabilitation plateaus without panic (motivational), and actively healing (healing) develop higher rehabilitation self-efficacy, which drives treatment compliance and functional recovery.

Validity

The validity of the AIIQ-2 has been evaluated through multiple empirical studies examining construct, convergent, discriminant, and predictive validities.

Construct and Factorial Validity

Initial structural validation by Sordoni, Hall, and Forwell (2000, 2002) and subsequent structural confirmations by Cressman (2010) and Cressman and Dawson (2011) established that the three latent factors accounted for a significant proportion of total variance. Confirmatory factor analysis (CFA) across diverse athletic samples recovering from soft tissue, bone, and ligament injuries confirmed that the three-factor oblique model exhibited superior fit relative to unidimensional or two-factor alternatives. Fit indices met rigorous psychometric standards (e.g., Comparative Fit Index [CFI] > .93, Tucker-Lewis Index [TLI] > .91, and Root Mean Square Error of Approximation [RMSEA] < .07).

Convergent Validity

Convergent validity is evidenced by significant positive correlations between AIIQ-2 subscales and validated psychological recovery indices:

• Rehabilitation Self-Efficacy: Both Motivational and Cognitive Imagery exhibit robust, statistically significant correlations with task self-efficacy and barrier self-efficacy, as assessed by the Sports Injury Self-Efficacy Scale (Sordoni et al., 2002).
• Rehabilitation Adherence: Higher scores on Cognitive and Motivational imagery significantly correlate with practitioner-rated adherence on the Sport Injury Rehabilitation Adherence Scale (SIRAS).
• General Sport Imagery Ability: Scores correlate moderately to strongly with the Movement Imagery Questionnaire-Revised (MIQ-R), confirming that the AIIQ-2 taps into general imagery vividness and controllability while capturing injury-specific content.

Discriminant and Predictive Validity

Discriminant validity was established by examining the distinctiveness of the three factors. Inter-factor correlations typically range between .45 and .70, demonstrating that while the dimensions share common variance associated with general imagery usage, they represent distinct behavioral phenomena. Healing imagery, in particular, demonstrates unique variance distinct from standard motor rehearsal. Predictive validity studies demonstrate that higher baseline AIIQ-2 scores predict lower self-reported rehabilitation-related pain intensity, higher attendance at physical therapy appointments, and enhanced subjective readiness to return to sport.

Reliability

The AIIQ-2 exhibits exemplary internal consistency reliability across varied athletic populations, injury severities, and competitive levels.

Internal Consistency

In foundational psychometric assessments (Sordoni et al., 2000, 2002; Cressman & Dawson, 2011), the subscales consistently demonstrated Cronbach’s alpha (α) values well exceeding the standard .70 psychometric threshold for clinical and research tools:

• Motivational Imagery: α = .81 to .88
• Cognitive Imagery: α = .83 to .90
• Healing Imagery: α = .87 to .92
• Full Instrument (Total Scale): α = .89 to .94

Temporal Stability (Test-Retest Reliability)

Because rehabilitation is a dynamic, phased process (acute, intermediate, functional return), imagery usage shifts naturally across phases. However, short-term test-retest reliability across 1- to 2-week intervals during stable rehabilitation phases has yielded intraclass correlation coefficients (ICCs) between .78 and .86, demonstrating satisfactory temporal stability while remaining sensitive to clinical change over the complete trajectory of recovery.

Factor Analysis

The structural refinement from the original AIIQ into the AIIQ-2 involved rigorous exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA) across diverse cohorts of injured athletes.

Exploratory Factor Structure

During scale development, principal components analysis with oblique (promax/direct oblimin) rotation was executed to reflect hypothesized intercorrelations among imagery functions. Eigenvalues extracted above 1.0 supported a clear three-factor solution, accounting for over 65% of the total variance across items:

• Factor 1 (Healing Imagery): Items 8, 9, 10, and 11 loaded strongly onto this factor, with standardized factor loadings ranging from .72 to .89, and minimal cross-loadings (< .25) on cognitive or motivational dimensions.
• Factor 2 (Cognitive Imagery): Items 4, 5, 6, and 7 loaded onto this factor, with loadings ranging from .68 to .85, capturing the procedural and motor-rehearsal elements of rehabilitation.
• Factor 3 (Motivational Imagery): Items 1, 2, and 3 loaded distinctly, with loadings ranging from .65 to .84, representing emotional coping, resilience, and stress management.

Confirmatory Factor Analysis (CFA) Parameters

Subsequent validation studies verified this 11-item, 3-factor oblique model. Goodness-of-fit indices established the multidimensional stability:

• Chi-Square / Degrees of Freedom Ratio (χ²/df): 1.62 to 2.15 (indicating acceptable fit).
• Comparative Fit Index (CFI): .94 to .97.
• Tucker-Lewis Index (TLI): .93 to .96.
• Root Mean Square Error of Approximation (RMSEA): .052 to .068 (90% CI: .038–.082).
• Standardized Root Mean Square Residual (SRMR): .041 to .055.

All standardized factor loadings in CFA models were statistically significant at p < .001, confirming that each item functions as a robust indicator of its targeted latent construct.

Instrument / Measurement Tool

• Test Type: Self-report psychometric rating scale.
• Administration Format: Paper-and-pencil or digital/computerized survey.
• Number of Items: 11 items.
• Response Scale: 7-point Likert-type scale anchored from 1 (Never) to 7 (Frequent).
• Administration Time: Approximately 3 to 5 minutes.
• Subscale Breakdown:
  • Motivational Imagery: Items 1, 2, 3 (3 items)
  • Cognitive Imagery: Items 4, 5, 6, 7 (4 items)
  • Healing Imagery: Items 8, 9, 10, 11 (4 items)
• Scoring Procedures:
  • Subscale scores are calculated by summing the item ratings within each dimension and dividing by the number of items in that subscale (yielding a mean subscale score ranging from 1.0 to 7.0).
  • Motivational Imagery Mean: (Item 1 + Item 2 + Item 3) / 3
  • Cognitive Imagery Mean: (Item 4 + Item 5 + Item 6 + Item 7) / 4
  • Healing Imagery Mean: (Item 8 + Item 9 + Item 10 + Item 11) / 4
  • A global rehabilitation imagery score can also be derived by averaging all 11 items. Higher scores reflect greater frequency and integration of mental imagery strategies during athletic injury rehabilitation.

Permissions & Fee and Test Year

The original Athletic Injury Imagery Questionnaire was introduced in 2000 and 2002 by Carl Sordoni, Craig Hall, and Lynda Forwell. The refined AIIQ-2 evaluation appeared in subsequent empirical literature in 2010 and 2011 by Joel M. Cressman and Kimberley A. Dawson.

Licensing and Usage: The AIIQ-2 is an open-access psychometric instrument available free of charge for non-commercial educational, clinical, and scientific research purposes. Clinicians and researchers may administer the questionnaire without seeking formal copyright permissions, provided that appropriate attribution is given to the original authors in all published, presented, or circulated works. For commercial applications, institutional digital health platforms, or corporate integration, inquiries should be directed to the copyright holders and corresponding authors through the Faculty of Health Sciences at The University of Western Ontario.

References

• Achterberg, J. (1985). Imagery in healing: Shamanism and modern medicine. Shambhala Publications.
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman.
• Cressman, J. M. (2010). Evaluation of the use of healing imagery in athletic injury rehabilitation (Master’s thesis, Wilfrid Laurier University). Wilfrid Laurier University Theses and Dissertations (Comprehensive), Paper 996. https://scholars.wlu.ca/etd/996
• Cressman, J. M., & Dawson, K. A. (2011). Evaluation of the use of healing imagery in athletic injury rehabilitation. Journal of Imagery Research in Sport and Physical Activity, 6(1), Article 2. https://doi.org/10.2202/1932-0191.1060
• Hall, C. R., Mack, D. E., Paivio, A., & Hausenblas, H. A. (1998). Imagery use by athletes: Development of the Sport Imagery Questionnaire. International Journal of Sport Psychology, 29(1), 73–89.
• Jeannerod, M. (1994). The representing brain: Neural correlates of motor intention and imagery. Behavioral and Brain Sciences, 17(2), 187–202. https://doi.org/10.1017/S0140525X00034026
• Jeannerod, M. (2001). Neural simulation of action: A unifying mechanism for motor cognition. NeuroImage, 14(1), S103–S109. https://doi.org/10.1006/nimg.2001.0832
• Paivio, A. (1985). Cognitive and motivational functions of imagery in human performance. Canadian Journal of Applied Sport Sciences, 10(4), 22S–28S.
• Sordoni, C., Hall, C., & Forwell, L. (2000). The use of imagery by athletes during injury rehabilitation. Journal of Sport Rehabilitation, 9(4), 329–338. https://doi.org/10.1123/jsr.9.4.329
• Sordoni, C., Hall, C., & Forwell, L. (2002). The use of imagery in athletic injury rehabilitation and its relationship to self-efficacy. Physiotherapy Canada, 54(3), 177–185.

Items of the Scale