Although the process of rehabilitation has traditionally been viewed as ‘physical’ in nature, it is now considered a multi-faceted process involving not only the services of surgeons and physiotherapists but also exercise scientists, dieticians, athletic coaches and sport psychologists (1).
Over the last decade, researchers have become increasingly interested in the psychological impact of injury and how athletes react to being hurt. This has spawned an advancement of knowledge about the psychological adjustments made by athletes during times of injury, and the subsequent impact of these on mental state and adherence to rehabilitation programmes. Although ideally the psychological support of injured athletes should be provided by psychology professionals, in practice it is very often administered informally by physiotherapists. Although physiotherapists generally consider psychological components of injury as important, recent research suggests that most feel limited in their abilities to deal with these concepts and consider additional training as necessary (2). Further, a related study of patient perspectives indicated that injured athletes felt that physiotherapists and other members of the healthcare team had not consciously considered the emotional impact of their injuries (3).
This article aims to present an overview of research findings from studies of the psychological impact of injuries. These might be useful for those working with injured athletes and potentially draw attention to issues of service delivery.
As an ex-athlete who sustained a serious knee injury during the early 1990s, I am well aware of both the physical and psychological journey that athletes undertake during rehabilitation. In my case, the 10-month post-operative phase following an anterior cruciate ligament (ACL) reconstruction involved emotional highs and lows, progressions, setbacks and, ultimately, a return to competition. For me, the key factors that helped my progress were the physiotherapists/social support, a high level of intrinsic (self-) motivation and, perhaps most importantly, goal-setting and goal-achievement. Having goals helped me focus on what needed to be done in order to reach my objective of a return to action. These goals boosted my motivation during the low points and helped me retain positive thinking patterns. I will return to these themes shortly to provide some examples of how to promote sustained motivation during long rehabilitation phases, but first of all it is important to understand an athlete’s initial psychological reaction to injury.
With serious injuries that are likely to result in a significant period of time out of the sport, athletes will often experience emotional disturbances. Researchers (4) suggest that athletes often follow a five-stage process following injury:
After the initial shock is over, many athletes tend to play down the significance of the injury. However, as the injury becomes more apparent, shock is often replaced by anger directed internally toward themselves or externally towards other people. The responses can vary in intensity depending on situational and personal factors but can be especially strong in individuals whose self-concept and personal identity are based on being ‘an athlete’. The loss of identity due to an inability to perform can cause much distress.
Following anger, the injured athlete might try bargaining/ rationalising to avoid the reality of the situation. A runner may promise herself to train extra hard or to be especially pleasant to those around her if she can recover quickly (5). By confronting reality, and cognitively realising the consequences of the injury, an athlete can become depressed at the uncertainty of the future. It must be noted, however, that depression is not inevitable and has not always been observed during the grief reaction in research studies.
Finally, the athlete moves towards an acceptance of the injury and focus is directed to rehabilitation and a return to sports activity. This stage tends to mark the transition from an emotional to a problem-coping focus as the athlete realises what needs to be done to aid recovery. The timescale for progression through these stages can vary considerably and setbacks during rehabilitation can lead to further emotional disturbance. In cases of very serious injury and ones in which the emotional reactions are prolonged, the skills of a clinical psychologist might be required.
A number of other reactions to injury can be caused by being sidelined and having plenty of time to worry. In one study, researchers found evidence that fear of re-injury, anxiety, and questioning of their own abilities to recover were reported by a significant number of injured athletes (6). More recent research (7), which investigated the subjective experiences of patients following ACL reconstructions, highlighted fear of re-injury as having associations with those who did not adhere to the rehabilitation programme. This fear may be linked to a reduction in self-motivation for such patients and avoidance rather than approach behaviours. Thus, what appears to be lack of motivation on the part of the injured athlete might actually be a symptom of emotional distress. Although these findings only represent qualitative data, there are implications for future researchers to establish if interventions to reduce this fear of re-injury might improve the adherence to rehabilitative programmes.
In reality, although some athletes experience negative emotions during the adjustment process, most cope without great difficulty (6). Positive adaptation can be helped by reducing the uncertainty surrounding rehabilitation and the recovery process. Psychologists recognise uncertainty as one of the major triggers for anxiety, but by educating the patient about the injury and what to expect during the rehabilitation phase this uncertainty can be reduced. Although individuals differ in the way they cope with injury and how much information they require, it is probably best to prepare the athlete for the difficulties of the process. Other applied sport psychologists take a similar approach to athletic counselling and suggest that by acknowledging the difficulties, the athlete is less likely to be deterred by unforeseen occurrences.
Sport and exercise psychologists Robert Weinberg and Daniel Gould suggest that providing the injured athlete with an approximate timescale for achieving certain goals during rehabilitation is important. For example, knowing that if things go well and compliance with the rehabilitation programme is maintained, that by week 4 (as appropriate) exercise cycling could be possible, to help to maintain a patient’s motivation. During my own rehabilitation a number of clear targets helped me keep positively striving for progress. These included regaining full range of motion at the joint, walking without a leg-brace, swimming, cycling, running on a trampette, running on grass and returning to competitive action (the dream goal). These markers are good examples of what psychologists call intermediate goals – the stepping stones that pave the way to achieving the dream goal. This approach can help combat any feelings of self-doubt that can arise from only focusing on the long journey towards a dream goal. Intermediate goals provide direction for the day-to-day efforts of the injured athlete. Physiotherapists can also help to provide short-term goals in the form of daily exercises that should be performed by the athlete. Goal achievement is especially good for increasing an athlete’s self-confidence.
You can get a clearer idea of how this process works by picturing a staircase where each step reflects an important marker for rehabilitation and the top of the stairs is the dream goal. In order to engage patients in this process it can be helpful to ask them to record and chart their progress. Their self-confidence can be enhanced by knowing how far they have already moved towards the dream goal. Thus, monitoring and evaluation of goals are important, as is re-setting goals that are too easy or too difficult to achieve in a given timescale. The importance of the psychological appraisals that athletes undertake regarding progress should not be underestimated. A recent study showed that therapist support and progression of exercises were identified as being important determinants of attendance at physiotherapy sessions (7).
Furthermore, a study of athletic trainers involved in the rehabilitation of athletes (8) identified differences between athletes who coped either more or less successfully with their injuries. Results revealed that a willingness to listen, maintaining a positive attitude and intrinsic motivation distinguished those who coped more successfully from their less successful counterparts.
Being able to detect those athletes who are not adjusting to their injuries at an early stage can help to establish the necessary support. Poor adjustment can manifest itself in non-compliance or adherence to rehabilitation programmes, with some athletes doing too little while others may push too hard. Physiotherapists have identified non-compliance as a significant problem preventing effective and efficient recovery from injury. One study (6) identified a number of key characteristics in athletes who experienced difficulties in adjusting to their injuries. These included:
It is necessary to be particularly aware of athletes who almost obsessively ask about returning to their sport. Having a desire to recover is healthy but some athletes over-estimate their capabilities and risk re-injury by over-stretching themselves. During attendance at knee clinics I came across a good example of this – a skier who had suffered an ACL injury and had undergone a reconstruction. Having reached the stage of being able to cycle for the first time in the presence of a physiotherapist, this athlete over-estimated her recovery progress. The first cycling session lasted just 10 minutes and was apparently taken as the green light for resuming more intense training. Without consulting her physiotherapist, the skier completed a 20-mile outdoor cycle ride (in her own time) only a few days after the initial cycling session. The predictable result of skipping the steady progressions caused increased swelling and a loss of range of motion at the joint, and rehabilitation was inevitably prolonged.
The process of adjustment can be helped or hindered by the injured athlete’s own personality. Some people perceive uncontrollable negative events as internal (‘it’s all my fault’), stable (‘it’s never going to get better’) and global (‘it’s going to affect everything I do’). Such thinking has been called a pessimistic explanatory style and some people are more prone to it than others. Contrast these feelings with a more optimistic approach (‘I couldn’t have done anything about it, but my injury will mend and it’s not going to affect the other good things in my life’) and you can clearly see the barriers to progress and the psychological damage that is being self-inflicted in the former example.
Research evidence has shown that pessimism is linked to continued distress following devastating losses (9). Investigators following a sample of people who had suffered terrible losses and trauma as a result of Hurricane Andrew suggested that it’s not how much you lose that predicts your state of mind but how you think about the loss. This is where social support is particularly necessary and challenges to irrational beliefs or maladaptive thought processes are particularly needed.
Forms of pessimistic thinking can be dismantled by rational analysis through helping injured athletes to explore their own feelings and the meanings they attach to their current situation. Verbal encouragement can help and reframing negative statements made by the athlete into more optimistic positive ones that are rehearsed and spoken by the athlete as part of his or her own internal dialogue (self-talk) can lead to more positive approaches to rehabilitation. Helpless and hopeless phases such as ‘I am getting nowhere fast’ and ‘Ill never regain full range of movement’ can be reframed into more positive alternatives such as ‘I’ve made some progress and if I keep working hard full range of motion will eventually return’. For the athlete to rehearse regularly this can be shortened to: ‘keeping to the programme will lead to full range of motion’. This self-talk is instructional and motivational instead of being negative. Rehearsal is the key to success and over time the injured athlete will start to harbour more positive beliefs and expectations.
These established techniques – goal-setting and self-talk – are two of the most important in the rehabilitation process. These techniques have been shown to be positively associated with adherence to rehabilitation programmes (10) and with faster healing times (11).
The psychological impact of injury can affect an athlete long after the body has successfully healed. For this reason the role of a trainer or coach is particularly important in the progression from the rehabilitation clinic to full competition. Both the performance and self-confidence of the athlete will likely be lower than pre-injury and this can be tackled by implementing a steady process of goal-setting and achievements to build both factors (much like the earlier example). On occasions, the circumstances surrounding the initial injury might cause negative memories and expectations that need to be worked through with a sport psychologist.