Coping with sports injuries II

Victor Thompson explains how the sports psych can help the athlete who is struggling with rehab

In the last issue I looked at how two athletes with what looks like the same injury might recover in very different ways. Some adjust quickly and well to their injury, whereas others have much greater difficulty accepting it and doing what is required to rehabilitate.

I explained how the meaning the injury has to an athlete can strongly influence its psychological and behavioural impact on them; in some cases causing a perception of significant losses, in others, significant anxiety and fears for their future.

The purpose of this article is to outline the kinds of interventions a sports psychologist might apply to help an injured athlete who is not coping well. This should help sports support professionals to appreciate more fully the role of a psychologist as an allied professional, in order to decide when it might be helpful to refer on an athlete who is struggling after injury.

It should be noted at the outset that not all sports psychologists are trained to provide all of the interventions outlined below, so the therapist will need to check out their credentials before referring on.

First, it is useful to consider briefly what the sports therapist themselves might think about referring a client onto a sports psychologist and what this communicates to the athlete:

Do I feel comfortable with the idea of making such a referral, or do I break out in a cold sweat? Would I be able to sell the benefits of a psychologist to the athlete well or only half-heartedly?

To make any onward professional referral is not an admission that you have failed, but proof that you recognise another professional may have the expertise to help the athlete with their current difficulties (be that physical, technical, dietary, psychological, etc). A psychologist can teach the athlete mental skills (similar to physical or technical skills), that will make them psychologically stronger and more robust.

They can help the athlete review situations, hypothesise about causes, draw lessons and do things differently in the future so they get more of what they want (eg, a quicker rehabilitation, improved performance, higher motivation). They can help the athlete understand the struggles and setbacks that can seem out of character and rather scary, so they bounce back more quickly.

Most psychologists don’t have a couch, or focus on childhood history or attempt to reveal the unconscious. Instead they usually focus on current difficulties, only drawing on other history where relevant. If you seek out a psychologist whom you’ve never met, I’d suggest giving them an outline of the type of difficulties your athlete is having and ask them how they might go about helping them. Then, if you want to refer, you’ll feel more confident about the psychologist’s input.

How is the athlete dealing with loss?

Not being able to play, train, practise or compete can come as a huge blow to an athlete, often producing anger at the unfairness of being sidelined with injury, especially if they believe they weren’t to blame (eg, an illegal tackle on the football field or being hit by a drunk driver en routehome).

The psychologist’s job will be to explain that this reaction is understandable and normal (to normalise), educate the athlete that it can often take a while to adjust, and to check out whether this frustration or anger is associated with any risky behaviour such as physical violence, verbal aggression, increased alcohol consumption, etc. If there are signs of increased risk, the psychologist will prioritise the management of these.

The next goal will be to work with the athlete to accept what has happened, recognise that setbacks do happen, that none of us can go back and change the past, though we can deal with the challenges of the present and move closer to getting back to full function (where possible).

A second common reaction to the athlete’s sense of loss is depression. Again, the psychologist’s priority is to assess risk. The main risk is of suicide, but there is also risk of self-injury or neglect. As with the angry athlete, the psychologist will usually work to normalise the experience of depression that arises from losing something very important. While the depressed state will usually resolve without intervention (possibly over several months), this process can be fasttracked by helping the athlete achieve small and meaningful goals, see progress in their rehabilitation and in other areas of life, socialise more, engage in interests and pastimes or find other sports that they can participate in during their recovery.

A psychologist working within a cognitive-behavioural framework would also help the athlete find links between what they are feeling (depression, despair, hopelessness) and other aspects of their state:

* cognition: the thoughts going through their mind, phrases, statements, or images they ‘see’ (such as getting injured at every training session)

* behaviour: doing or not doing things, such as staying in bed all day, not eating well, not doing rehab exercises, not seeing friends

* bodily sensations: lethargy, pain in injured area.

In team sports, an injury may prevent an athlete from being able to practise with teammates. This reduction in social interaction, camaraderie and banter can be sorely missed – particularly if the athlete doesn’t have other opportunities for meaningful interactions during his/her week. The psychologist will help here by working with the athlete to replace or substitute for the losses (eg, initiating and responding to more social gatherings with friends inside and outside sport) and to engage in alternative physical activities where possible (cycling instead of running; swimming instead of rowing; aqua running instead of track sprinting), so that the athlete continues to get the positives from exercise.

The psychologist might explore whether the athlete could attend practice sessions and watch, or help the coaching staff with some tasks, even things as basic as fetching and carrying. This will give the athlete opportunities to interact with players and coaches, while remaining up to date with any team changes.

Despite an injured athlete’s best efforts, however, team-mates and coaching staff might not be welcoming. The psychologist will explore with the athlete why this might be: perhaps team-mates would rather not have to contemplate that the same injury could easily happen to them, especially one that has serious consequences (eg, the rugby player with a broken back). Or perhaps a macho sporting culture refuses to allow any display of sympathy.

Moreover, not all managers will be eager to encourage their injured athletes to be seen hobbling around at practice sessions or competitions. This change in relationships might add to the injured athlete’s sense of loss. Indeed, a psychologist may end up being the only one able to offer empathy and a listening ear, without being judgemental, casting blame, dismissing concerns, or pressuring the athlete to hasten their return to play.

How is the athlete dealing with anxiety?

Fear or anxiety is a common reaction to injury. It is natural to be concerned about one’s progress and the risk that an injury will recur. The psychologist’s role will be to assess whether this concern has developed into a more intense fear and anxiety, which has created an extra layer of problems for the athlete.

Within the cognitive-behavioural framework, a psychologist will look out for cognitive changes – the athlete having exaggerated worries about:

* the likelihood of a significant setback

* the severity of such setbacks

* their confidence in their ability to cope or be helped by other people if a setback were to happen.

The psychologist would then help the athlete look at these specific fears, question how reasonable and useful these beliefs might be, testing and challenging the ones that are fuelling fear.

The psychologist may also want to identify and challenge changes in the athlete’s behaviour, such as making frequent checks for signs of progress or re-injury, becoming overly cautious, or going to extremes to keep safe and avoid re-injury. One tool here is to jointly generate a programme to face up to key situations or scenarios that the athlete is avoiding, in a graduated and manageable way (this is known as a fear hierarchy).

Anxiety may well manifest itself physically: increased muscular tension (frequently in the neck and shoulders, or in tension headaches) heart palpitations, gastric difficulties. So the psychologist may teach a range of relaxation techniques, such as:

* breath control

* progressive muscular relaxation

* release-only relaxation.

Behavioural experiments can be set up to test out some fears. For example, if the athlete believes ‘If I put all my weight on my injured leg, the injury will be worse than ever’, an experiment would be designed directly to test the perceived need to over-protect the injured leg. As with any other aspects of the programme, the psychologist should conduct any physical challenges such as this only with the endorsement of other key professionals such as the physio or sports physician.

A drop in confidence

In many ways confidence is the opposite of anxiety. The longer the athlete is away from training and competition, the more likely they are to lose confidence in their ability to get back on top of things. Here, the role of the psychologist will be to work with the athlete and coaching staff to identify the specific aspects of the sport that the athlete has lost confidence in. This information will then be included in a graduated programme of performance simulations, training tests and other assessments to evaluate the strength and durability of the rehabilitated body part and the readiness of the athlete.

This evidence will help restore the athlete’s confidence. And if it doesn’t, it will flag up for the psychologist other areas that still warrant attention.

What has injury taught the athlete?

Some athletes obsess about the incident that caused their injury, going over and over it without ever generating additional useful information or closure on what went wrong. Others, in contrast, seem to give the incident hardly a second thought. Either of these positions can lead to difficulties.

The psychologist will think through the incident methodically with the athlete, to try to find learning points – things that the athlete or people around the athlete could do differently next time to reduce the probability of another injury. The psychologist may also look for any emotionally laden time points or gaps in the retelling of the incident that may offer clues as to why the athlete is struggling to come to terms with it.

The value of imagery

Imagery work can be a very powerful performance tool, but it is generally underused by athletes. Rehab can be the ideal time for an athlete to learn about imagery and develop the necessary skills, which the psychologist can help to teach. There is plenty of evidence that should persuade even the most hardened sceptics (therapists or athletes) to give it a try. For example:

* More than nine out of 10 US Olympic athletes questioned by Orlick and Partington(1)and Canadian Olympians questioned by Murphy, Jowdy and Durtschi(2) used imagery.

* Athletes have used imagery to increase blood flow to injured areas and reduce recovery time(3,4)..

* Sitting and thinking through sport-specific moves sends small impulses to the same muscles that the athlete uses when performing the moves for real. This mental practice helps maintain sport-specific skills, reducing the time required to regain performance standards(5).

In imagery work the athlete first relaxes, using breath control or similar techniques. Then they create an image of a scenario by drawing on each of their senses (touch, taste, smell, seeing and hearing). The athlete adds into this scenario their emotions, thoughts and feelings. Over time, the athlete is trained to develop the vividness and controllability of their images – like a movie director – stopping, rewinding, zooming in, and changing what action happens.

The athlete can then run through imagined situations that are likely to be most helpful: images of their body healing, with blood flushing the area and taking away toxins; images of performing their rehab exercises or their sport-specific moves; of training, or of competition. The number of scenarios that can be created is limitless. I find that even the most sceptical athlete can get hooked on imagery work, because it is both helpful and highly portable.

Conclusion

A sports psychologist can have an important role in helping an injured athlete cope with their injury and its impact. Far from giving every athlete the same ‘psychological programme for injury’, the most useful approach is individualised, commencing from an understanding of what difficulties thisathlete has and why, then developing a personalised intervention to fit.

The sports psychologist can become an important member of the rehab team. Not all injured athletes need to see one, but many can benefit, and in a range of different ways. In addition, the psychologist can offer an understanding to the other professionals and coaching staff on why some athletes might be experiencing difficulties and on what might be helpful.

References

1. Orlick, T and Partington, J (1988) ‘Mental links to excellence’. The Sport Psychologist. 2, 105-130.

2.Murphy, S, Jowdy, D and Durtschi ,S (1990) Report on the US Olympic Committee Survey on Imagery use in Sport.Colorado Springs, CO, US Olympic Training Center.

3.Ievleva, L and Orlick, T (1991) ‘Mental inks to enhanced healing’.The Sport Psychologist. 5(1), 25-40.

4.Smith, D, Holmes, PS and Colins, DJ (1998) ‘The effect of mental practice on muscle strength and EMG activity’. In Proceedings of the British Psychological Society. p22. Leicester, British Psychological Society.

5. Slade, JM, Landers, DM, and Martin PE (2002) ‘Muscular activity during real and imagined movements: A test of inflow explanations’. Journal of Sport & Exercise Psychology. 24, 151-167.