Rehabilitation of Injury and Return to Sport

Returning to a sport following an injury can be difficult. The individual can feel pressure from themselves or those surrounding them, to return and compete at pre-injury level (Podlog & Dimmock, 2011, 12(1), p. 36-42). The athlete will need to overcome any doubt they have and work on their mental toughness. Ultimately, the idea of returning to sport following an injury is the aim for most athletes.

 

Research has provided information in regards to what the athlete should primarily focus on when returning from injury. A study conducted by Podlog & Eklund (2005, 14(1) p. 20-34) revealed that intrinsic motivations for returning to competition were associated with a positive renewed perspective on sport participation. Setting achievable goals, and obtaining motivation and determination when the individual has returned to sport has them concentrating on taking necessary steps in returning and playing at an optimum level. Intrinsic motivation refers to engaging in an activity for itself and for the pleasure and satisfaction derived from participation (Vallerand, R J., 2004, p. 427-430). In 1992, Vallerand and colleagues proposed and showed that there are at least three types of motivation. These included intrinsic motivation to know, towards accomplishments and to experience stimulation (Vallerand, R J., 2004, p. 427-430). All three of these aspects allows the individual to feel the pleasure of learning, as well as trying to exceed themselves and for the aesthetic and sensory pleasure of playing, and as a result, allow athletes to begin feeling comfortable playing post-injury.

 

Recent literature has highlighted the adversity injured athletes are faced with when returning from sport, with a range of psychosocial concerns. The results suggest that athletes returning to sport from injury may experience concerns related to their sense of competence, autonomy and relatedness (Podlog L, Dimmock, J & Miller, J., 2011, 12(1) p. 36-42). This is concerned as poor self-confidence; creating anxiety can lead to much bigger problems such as depression and even substance abuse.

 

Self-efficacy is something the individual athlete needs to develop to overcome their sense of poor confidence and autonomy. The self-determination theory (SDT) is a theory of motivation, where the athlete needs to have self-belief and drive if they are to have any success when they return to sport. This theory can assist in overcoming the self-doubt some may have, which can therefore overcome any negativity related to returning to sport from injury. For self-determination to improve, Ryan & Deci (2000) concluded that the environment must satisfy three basic psychological needs, namely competence, autonomy and relatedness (Podlog. L, Eklund. R. C., 2010, 28(8), p. 819-831). Three distinct types of primary appraisals have been identified that assist in self-determination (Gagne, et al., 2003), which are goal relevance, motivational congruence and ego-involvement. These factors also support previous research that flexible goals focusing on skill development are likely to foster a sense of competence (Podlog, L. & Dionigi, R. 2010, 28(11), p. 1197-1208), which tends to be absent when an athlete returns from an injury.

 

Taylor and Taylor (1997) produced a stage model on the return to sport of an athlete. This model was composed of five physical and psychological stages. They also suggested that adaptation was likely to occur as the athlete came to accept the injury, recognises the inevitability of what the future may hold, and receives social support to alleviate negative emotions (Podlog, L. & Eklund, R C., 2007, 8(4), p. 535-566). These support the base of the self-determination theory, and highlight the importance of the theory’s constructs.

 

There are necessary developments for future research when athletes are returning from sport post-injury, as there is little agreement that exists in regards to the meaning of a ‘successful’ return. Competitors are increasingly pressured to return to sport as soon as they can, which can lead to them returning before they are ready, not just physically, but also psychologically, increasing the chance of a re-injury (Bauman, J., 2005, 15(6), p. 432-435). The SDT has potential for understanding findings in this area and for guiding future research (Podlog, L. & Eklund, R C., 2009, 10(5), p. 535-544) ensuring athlete’s needs are being met, which may produce positive return-to-sport outcomes.

the psychological and physical risks of playing through an injury

In my blog I will talk about the pressures of playing through injury and illness in professional sport and the mental and psychological effect on the athletes` ability to perform.

It is a reality that most athletes will experience an injury (or illness) at some point in their career. Depending on the type of injury, severity, and the time at which it (injury) occurs in the athletes career, the individual`s mindset and emotional health has the potential to be impacted negatively, resulting mental health issues Nixon HL, ll (1996).   There are many factors that can contribute to the deterioration of the mental health of the athlete, one being, psychological pressure placed upon the athlete to compete and excel regardless of their illness or injury (Kyle et al., 2006).  These expectations are often unrealistic and may result in harsh criticism for those injured athletes who are not able to fight through the pain of the injury and continue to play, or be willing to risk further injury to themselves.

Culturally, there is a belief in sport that if you are physically able to play, you must and that anything less is not acceptable.  The reaction to an athlete that overcomes an injury or illness to have a positive result on the game has gone from being one of adulation to now being that of expectation (Greenleaf et al., 2001).. This change in expectation places a whole new type of pressure on the modern day athlete that has never existed in the past.

In the 1990`s, when televised sports were really becoming increasingly accessible and popular in society, the community perception was that of pure amazement while watching the likes of Michel Jordan scoring 38 points while suffering with the flu in a vital playoff game, ignoring the risk of damaging his heart.  At that point in time, playing while ill or injured was not normal accepted behaviour. However, with the creation of social media and its use in the sporting arena, there is a new and unfounded criticism of those who are either not able to replicate the feats of those from the past, or those who are not willing to further damage their bodies in the pursuit of those accomplishments.

The added pressure that athletes now have with the constant criticisms coming from social media compounded with already existing stresses that comes with carrying an injury may start to have hugely negative effects on both the athletes` mental health and also their performance in their given field (Kyle et al., 2006). The anxiety that can be associated with playing with an injury can also be compounded with the stresses that come from constant criticism by the media.  After a bad performance by an athlete with a known injury, media will often question the athlete on the injury and their ability to perform. This has the potential to increase the level of anxiety over the injury, decreasing arousal, resulting in poorer performances O`Connell (2012). Further, if the injury is ongoing, prolonged anxiety and stress to perform over a long period can affect the immune system, leading to other illnesses.

It is not hard to find examples of the anxiety and stress athletes face when deciding whether or not to play with an injury and the resulting effects being easily viewable. Examples are outlined in Table 1.

Table 1. List of injured players, their decisions to play and the out comes

Player Injury Play/sit out Effectiveness Criticism/adulation
Rajon Rondo Dislocated elbow Played Played well/team lost Rondo received little adulation and received limited criticism
Dwight Howard Herniated disk in back/ torn labarum Sat out Team was losing Received harsh criticism for choosing not to play through pain
Dwight Howard Played Under preformed for him (still well)/ team was losing Criticism for not dominating position
Derrick Rose Torn acl Sat out Team was winning but needed him in finals Much debate if should return at under 100%  heavy criticism form fan base
Tony Parker Strained hamstring Played limited minuets Team performed well but lost Criticised for lack of value/reduce by other circumstances
Kerri Strug Sprained ankle Competed Won Adulation
Patrice Bergeron Separated shoulder, broken ribs, torn cartilage and muscles Competed Lost Adulation/ injuries because life threatening
Michael Jordan Flu Competed Won Adulation
Stephen Curry Ankle injury Competed Team remained competitive Neither/further damaged ankle

Taking two of the examples from the table above the risks to the athlete, physically and psychologically, can be examined easily.

During the 2013 Stanley Cup playoffs, Bruins centre Patrice Bergeron played the final game of the series having suffered a broken rib, torn cartilage in his ribs and separated shoulder the game before.  For Bergeron to enter the final game with these injuries, suggests substantial pressure, both internal and external, not to let his team down. The result was Bergeron was praised for his actions; however Bergeron suffered a punctured lung during the game, a potential life threatening condition Mcdonald (2013).

However, not every athlete will choose to take that route.  During the 2012-13 NBA season the Los Angeles Lakers centre Dwight Howard decided to sit out the start of the season.  Howard was suffering with a surgically repaired back and torn labrum.  He had the ability to play but would have been in extreme pain.  As a result of his decision, he was ridiculed by the media, past greats of the game and his then team mates until he gave into the pressures of playing.  Upon his return he was still the best centre in the league but as his team was losing, criticism continued.  After the season most journalists admitted they were probably too hard on him but justified it with “comes with the territory of playing under pressure for such a storied franchise like the Los Angeles Lakers” Vitti (2013).

The added pressure and stress that is being placed on athletes to play while injured could be having a huge detrimental effect on these athletes` health and wellbeing, both physically and mentally.  In the next part of my blog I may discuss potential strategies for the athlete to overcome these anxieties and stresses.

The Psychological Health of the Athlete Immediately Post Injury

As I sat on the couch last Saturday with a group of friends, supported by an array of chips, dips and alcoholic beverages watching my favourite AFL team the mighty Richmond Tigers, something struck me. The Game was going well until Reece Conca of the Richmond Tigers went in for a courageous tackle, I jumped up in excitement cheering for a possible turn over, and then my heart sank, Conca had stopped in his tracks and was grimacing in pain. A huge gasp could be heard from all of us watching, followed by a period of silence that seemed like a lifetime waiting for him to shake it off. He didn’t.  He was bouncing on one leg clutching at his left hamstring. It looked bad, the commentator later confirmed a complete tear of the left hamstring and he was out for not only the rest of the game but also the remainder of the season. It was at this point a friend said out loud “how would you feel? Knowing your season is over, how do you come back from that?” I found myself thinking ‘what is going through his head right now?’ And then my inner nerd kicked in ‘what are the immediate thoughts going through an athletes head when they injure themselves and what role does psychology play in an athletes recovery period?

With all the news coverage focusing on the physiological health and recovery of the athletes I was motivated to do a little research for myself and stumbled across some very interesting information. Overtime coaches and athletes, with the assistance of science, have built a strong understanding of what physiological factors are involved in a sporting injury. I was interested to discover that it is becoming more and more apparent that the immediate psychological distress that can manifest at the time of an injury can in fact hugely impact rehabilitation and the athlete’s ability to return to competitive play.[i]

Coaching staff are recognising the importance of an athletes mental state from the moment of the injury and through the entire recovery period[ii].  A lot of responsibility falls on surrounding teammates and coaching staff, relying on their ability to notice any changes in the athletes’ behaviour or mental state. [iii] At an elite level team psychologists are playing a bigger role with in the team. Current Fremantle assistant coach Simon Lloyd, was high performance manager and club psychologist at Collingwood from 2005 to 2008 and similar roles at Hawthorn previous to that[iv]. I find it very interesting that Elite Sporting teams are recruiting coaches with psychological skills, and in future blogs I will endeavour to find out exactly how people such as Simon Lloyd are utilized in high level coaching roles.  The Canberra Raiders do not in fact have a full time psychologist on their coaching staff, however, during the 2011 season a psychologist was bought in to try and combat athlete issues[v], thus highlighting the increasing recognition of psychological health and its relationship with performance management[vi].

Ranges of practices are being implemented in the sporting industry to measure the mental state of athletes. One such measure is the implementation of post injury questionnaires and interviews.[vii] Taylor and Taylor suggest that immediately post injury there are many factors that contribute, and cause possible psychological distress. These factors are; the suddenness of the injury, lack of control felt by the athlete, possible disruption to the athletes sporting goals, immediate and potential long term pain and discomfort caused and finally the uncertainty of how the injury will impact the athlete.iii Athletes have described initial reactions of fear, frustration, helplessness and interestingly anxiety as to how the coach will react to the diagnosis.  Common thoughts recorded are also, ‘Will I ever be able to play again?’ ‘Will I lose my spot on the team?’ ‘How will I financially support myself if I lose my place on the field?’ and ‘Will my teammates think I let the team down? [viii]

It has become more and more apparent that an athlete’s mental state is vital to a quick recovery. Psychologists are now used to identify issues effecting athletes mentally and to assist them in managing these issues, keeping athletes mentally and ultimately physically healthy. When an injury occurs athletes need to set themselves new and realistic goals to an appropriate timeline of rehabilitation in order to return to play. It is again the role of the psychologist to implement strategy and aid athletes in setting and hitting these goals[ix].

In regards to the role of psychology immediately after injury, the treatment choices are specific to individuals. The Athletes psychological health when injured seems to be quite strongly dependant on state of mind before the injury occurs, due to the extreme emotional impact on the athlete immediately post injury how can we develop a generic guide to go by? [x]

By Annie Gallacher


[i] Weinberg R and Gould D (2007) Foundations of Sport and Exercise Psychology. (4th ed). Human Kinetics, Champaign IL.

[ii] Shuer ML,Dietrich MS. (1997) Psychological effects of chronic injury in elite athletes. Western Journal of Medicine  Feb;166:104-109

[iii] Johnston, LH and Carroll D(2000). The Psychological Impact of Injury: Effects of Prior Sport and Exercise Involvement, British Journal of Sports Medicine, 34, 436-439.

[iv] Fremantle Football Club Coaching Staff, viewed 13 September 2013 http://www.fremantlefc.com.au/footy-centre/coaching-staff

[v] Barrett, Chris(2011) Honesty the policy for Raiders with season on the line. The Brisbane Times, viewed 13 September 2013 http://www.brisbanetimes.com.au/rugby-league/league-news/honesty-the-policy-for-raiders-with-season-on-line-20110506-1ebx3.html

[vi] Roh J.L, Perna F.M. (2000) Psychology/counseling: a universal competency in athletic training. Journal of Athletic Training. 35: 4,458–465.

[vii] Tracey, Jill(2003) The Emotional Response to the Injury and Rehabilitation Process, Journal of Applied Sport Psychology, 15: 4, 279-293

[viii] Taylor J and Taylor S (1997). Psychological Approaches to Sports Injury rehabilitation, Aspen Publishers, Maryland.

[ix]  Crossman, J(1997) Psychological Rehabilitation from Sports Injuries. The International Journal of Sports Psychology, 16, 232-237.

 

[x] Scheizer CB, Brewer BW, Cornelius AE, Van Raalte JL, Pepitas AJ et al(2001) Psychological skills and adherence to rehabilitation after reconstruction to the anterior cruciate ligament, Journal of Sport Rehabilitation, 10: 165-172

Injury Prevention & Psychology

Athletic competitive sports stress both the body and the mind (Naylor, 2009). Although it is easy to identify injured body parts during a collision in sport, the psychological stresses that athletes experience are not as obvious (Naylor, 2009). But just as insufficient rehabilitation increases the risk for re-injury, an athlete may be inadequately prepared for the demands of a certain sport if mental aspects are not implemented in an injury prevention training program (Naylor, 2009).Prevention is the action of stopping something from happening (Australian Pocket Oxford Dictionary, 2007) and this seems to be a continuous challenge to sports medicine (Hanson, McCullagh & Tonymon, 1992; Johnson, 2006). Derived from a number of studies, the most common psychological factors that influence the risk of injury include:

  • low self-esteem,
  • no confidence,
  • low motivation levels,
  • history of stressors,
  • coping resources and
  • certain personality characteristics such as high state-trait anxiety, negative attitudes, behaviours, mood states and in particular high stress responses (Andersen & Williams, 1988; Hanson, McCullagh & Tonymon, 1992; Lavallee & Flint, 1996; Larson, 1998; Maddison & Prapavessis, 2005; Johnson, 2006). It is therefore crucial that coaches or fitness professionals identify and understand how to implement all possible mental strategies during training sessions to prevent the risk of injury.

Based on a substantial history of literature, the most influential and subsequently revised stress-injury model was created by Andersen & Williams (1988) and aimed at predicting the occurrence of sport injury. The purpose of the model is to examine a representation of injury which involves intrapersonal, physiological, cognitive, attention, social, behavioural and stress history variables that may influence injury occurrence (Andersen & Williams, 1988). It hypothesizes that individuals that have a history of many stressors (life events, daily hassles, previous injuries) with certain personality characteristics, such as locus of control, hardiness and trait anxiety, tend to aggravate the stress response, and with few coping resources (social support system, general coping behaviours, stress management) in a highly stressful scenario, will more likely judge the situation as stressful (Andersen & Williams, 1988; Johnson, 2006). Consequently, they will show signs of greater muscle tension, attention disruption and perceptual narrowing on the field and thus be at greater risk of injury compared to athletes who have the opposite profile (Andersen & Williams, 1988; Johnson, 2006).

It is therefore evident that the implementation and assessment of controlled interventions for preventing injury in a sport setting is an important aspect in improving athletic performance. Andersen & Williams (1988) stress-injury model includes possible prevention interventions such as cognitive restructuring, concentration training, imagery rehearsal and mediation.

An intervention strategy that has been reported to be most effective is relaxation (Walsh, 2011). Relaxation refers to changes in the body that produce the opposite effects of the “fight or flight” response triggered by the sympathetic nervous system (Walsh, 2011). It is specifically associated with decreases in heart rate, respiration rate, oxygen consumption and skeletal muscle activity but it also increases production of alpha brain waves and skin resistance (Gould & Udry, 1994). It has become an attractive approach for stress reduction due to its ability to bring physiological functions under control as well as increases in self-efficacy and other cognitive variables (Gould & Udry, 1994). In theory, preventing injury and enhancing performance is possible via relaxation training but only limited studies provide evidence that do not produce strong conclusions. There also seems to be a lot of empirical support between psychological factors and injury outcome but the relationship between intervention programs and athletic performance are sparsely documented. It is therefore evident that future research must investigate further into the effectiveness of psychological prevention programs such as relaxation training to increase an athlete’s sporting performance.

Below is the model of stress-injury created by Andersen and Williams (1988):

Image

By Vanessa Gaynor

 

 

Reference List

  • Andersen, M.B., & Williams, J.M (1988). A Model of Stress and Athletic Injury: Prediction and Prevention. Journal Of Sport & Exercise Psychology, 10(3), 294-306.
  • Andersen, M.B. (1989), April). Psychosocial factors and changes in peripheral vision, muscle tension, and fine motor skills during stress. Dissertation Abstracts International, 49,
  • Gould, D., & Udry, E. (1994). Psychological skills for enhancing performance: Arousal regulation strategies. Medicine and science in sports and exercise,26(4), 478-485.
  • Hanson, S. J., McCullagh, P., & Tonymon, P. (1992). The relationship of personality characteristics, life stress, and coping resources to athletic injury. Journal Of Sport & Exercise Psychology, 14(3), 262-272.
  • Johnson, U. (2006). Sport injury, psychology and intervention: an overview of empirical findings. Int J Sport Exercise Psychol57, 1-10.
  • Larson, G. A. (1998). Psychosocial Variables: Predicting and Preventing Athletic Injury. Athletic Therapy Today, 3(1), 7-11.
  • Lavallee, L. L., & Flint, F. F. (1996). The relationship of stress, competitive anxiety, mood state, and social support to athletic injury. Journal Of Athletic Training, 31(4), 296-299.
  • Maddison, R., & Prapavessis, H. (2005). A Psychological Approach to the Prediction and Prevention of Athletic Injury. Journal Of Sport & Exercise Psychology, 27(3), 289.
  • Naylor, A. H. (2009).The Role of Mental Training in Injury Prevention. Athletic Therapy Today, 14(2), 27-29
  • Walsh, A.E. (2011). The Relaxation Response. A Strategy to Address Stress. International Journal Of Athletic Therapy & Training, 16(2), 20-23.